Provider Demographics
NPI:1265656953
Name:BRUNKHARDT, ALLEN KENT (RN)
Entity Type:Individual
Prefix:
First Name:ALLEN
Middle Name:KENT
Last Name:BRUNKHARDT
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:199 LAKEVIEW DR
Mailing Address - Street 2:
Mailing Address - City:WATAGA
Mailing Address - State:IL
Mailing Address - Zip Code:61488-9604
Mailing Address - Country:US
Mailing Address - Phone:309-368-6708
Mailing Address - Fax:
Practice Address - Street 1:2323 WINDISH DR
Practice Address - Street 2:
Practice Address - City:GALESBURG
Practice Address - State:IL
Practice Address - Zip Code:61401-9780
Practice Address - Country:US
Practice Address - Phone:309-344-4200
Practice Address - Fax:309-344-4281
Is Sole Proprietor?:No
Enumeration Date:2007-04-12
Last Update Date:2009-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL041-326520163W00000X, 163WC0400X
IA105104163W00000X
IL041.32650163WP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No163WC0400XNursing Service ProvidersRegistered NurseCase Management
No163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA105104OtherR N LICENSE
IL041.326520OtherRN LICENSE
IL370984175OtherBEAY INC FEIN