Healthcare Provider Details

I. General information

NPI: 1104269695
Provider Name (Legal Business Name): BRENDA HUNT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/15/2013
Last Update Date: 04/15/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

526 W STATE ST
ROCKFORD IL
61101-1214
US

IV. Provider business mailing address

1021 N MULFORD RD
ROCKFORD IL
61107-3877
US

V. Phone/Fax

Practice location:
  • Phone: 815-968-9300
  • Fax:
Mailing address:
  • Phone: 815-387-5600
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number041408515
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: