Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 152W00000X | Optometrist | 18004177A | IN |
NPI | 1013569243 |
---|---|
Provider Name | Bayley Marie Brunck |
First Address | Vienna, VA 22182-3970 |
Second Address | Bloomington, IN 47401-6177 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 09/07/2019 |
Last Update Date | 28/10/2021 |