Healthcare Provider Details

I. General information

NPI: 1114402021
Provider Name (Legal Business Name): DEBRA BRUNK CNS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/26/2018
Last Update Date: 09/26/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1428 E NORTHERN AVE
PHOENIX AZ
85020-4319
US

IV. Provider business mailing address

3738 E WELDON AVE
PHOENIX AZ
85018-5816
US

V. Phone/Fax

Practice location:
  • Phone: 480-442-0191
  • Fax:
Mailing address:
  • Phone: 480-442-0191
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133N00000X
TaxonomyNutritionist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: