Healthcare Provider Details

I. General information

NPI: 1861426017
Provider Name (Legal Business Name): VICKIE PLUNKETT DUNKELBERG CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/11/2006
Last Update Date: 01/16/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4200 S HULEN ST SUITE 425
FORT WORTH TX
76109-4914
US

IV. Provider business mailing address

4200 S HULEN ST SUITE 425
FORT WORTH TX
76109-4914
US

V. Phone/Fax

Practice location:
  • Phone: 817-731-2875
  • Fax:
Mailing address:
  • Phone: 817-731-2875
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number561456
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: