Healthcare Provider Details

I. General information

NPI: 1114461894
Provider Name (Legal Business Name): BRECK A HUNNICUTT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/14/2016
Last Update Date: 10/10/2022
Certification Date: 10/10/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11050 PARKVIEW CIRCLE DR
FORT WAYNE IN
46845
US

IV. Provider business mailing address

11109 PARKVIEW PLAZA DR # 117
FORT WAYNE IN
46845-1701
US

V. Phone/Fax

Practice location:
  • Phone: 833-724-8326
  • Fax: 260-425-6845
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number71007004A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code163WX0200X
TaxonomyOncology Registered Nurse
License Number28097044A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: