Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 363L00000X | Nurse Practitioner | 209-004016 | IL |
Y | 363LF0000X | Nurse Practitioner - Family Medicine | 209-004016 | IL |
NPI | 1003901471 |
---|---|
Provider Name | Debra Brunk |
First Address | Chicago, IL 60608 |
Second Address | Chicago, IL 60608 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 03/10/2006 |
Last Update Date | 13/05/2015 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
209-004016 | APN LICENSE# (01) | IL |