Provider Demographics
NPI:1124209713
Name:BRUNET, VICKY MADDOX (CNNP)
Entity Type:Individual
Prefix:
First Name:VICKY
Middle Name:MADDOX
Last Name:BRUNET
Suffix:
Gender:F
Credentials:CNNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:211 HUNTINGWOOD BLVD
Mailing Address - Street 2:
Mailing Address - City:LYNCHBURG
Mailing Address - State:VA
Mailing Address - Zip Code:24503-3815
Mailing Address - Country:US
Mailing Address - Phone:434-384-4550
Mailing Address - Fax:
Practice Address - Street 1:3300 RIVERMONT AVE
Practice Address - Street 2:
Practice Address - City:LYNCHBURG
Practice Address - State:VA
Practice Address - Zip Code:24503-2030
Practice Address - Country:US
Practice Address - Phone:434-200-4000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-11-24
Last Update Date:2007-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024084339363LN0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LN0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerNeonatal
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA54740NOtherSENTARA