=====================================================
General NPI Number Information
=====================================================
NPI Number | 1063614394
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | THEODORA J. BRONKEN M.A., CCC-A
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/31/2007
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 215 E ORMAN AVE
-----------------------------------------------------
City | PUEBLO
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 81004-2143
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 719-549-7693
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 549 W JUANITA SPRINGS DR
-----------------------------------------------------
City | PUEBLO WEST
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 81007-1881
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 719-547-4875
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 231H00000X
-----------------------------------------------------
Taxonomy Name | Audiologist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------