Provider Demographics
NPI:1629288600
Name:BRUCKNER, IRENE ELIZABETH (LMT, RN)
Entity Type:Individual
Prefix:
First Name:IRENE
Middle Name:ELIZABETH
Last Name:BRUCKNER
Suffix:
Gender:F
Credentials:LMT, RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16329 WEBER RD
Mailing Address - Street 2:
Mailing Address - City:LOCKPORT
Mailing Address - State:IL
Mailing Address - Zip Code:60441-6558
Mailing Address - Country:US
Mailing Address - Phone:815-725-9774
Mailing Address - Fax:
Practice Address - Street 1:200 N HAMMES AVE
Practice Address - Street 2:SUITE 2
Practice Address - City:JOLIET
Practice Address - State:IL
Practice Address - Zip Code:60435-6677
Practice Address - Country:US
Practice Address - Phone:815-773-2301
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL163W00000X, 225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered163W00000XNursing Service ProvidersRegistered Nurse
Not Answered225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist