Healthcare Provider Details

I. General information

NPI: 1861438392
Provider Name (Legal Business Name): DR. VICKIE BRUNK
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MISS VICKIE GORAN

II. Dates (important events)

Enumeration Date: 06/22/2006
Last Update Date: 12/07/2021
Certification Date: 12/07/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5893 COPLEY DR
SAN DIEGO CA
92111-7906
US

IV. Provider business mailing address

FILE #55745
LOS ANGELES CA
90074-5745
US

V. Phone/Fax

Practice location:
  • Phone: 858-616-5472
  • Fax:
Mailing address:
  • Phone: 619-644-9515
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code231H00000X
TaxonomyAudiologist
License Number3804
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code231H00000X
TaxonomyAudiologist
License NumberAU1787
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: