Provider Demographics
NPI:1861438392
Name:BRUNK, VICKIE
Entity type:Individual
Prefix:DR
First Name:VICKIE
Middle Name:
Last Name:BRUNK
Suffix:
Gender:F
Credentials:
Other - Prefix:MISS
Other - First Name:VICKIE
Other - Middle Name:
Other - Last Name:GORAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:FILE #55745
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90074-5745
Mailing Address - Country:US
Mailing Address - Phone:619-644-9515
Mailing Address - Fax:
Practice Address - Street 1:5893 COPLEY DR
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92111-7906
Practice Address - Country:US
Practice Address - Phone:858-616-5472
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-22
Last Update Date:2021-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA3804231H00000X
CAAU1787231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAWAU1787AMedicare PIN
CAWAU1787CMedicare PIN
CAWAU1787BMedicare PIN