Provider Demographics
NPI:1700207859
Name:BRUNKE, SUSAN DEANN (RN)
Entity Type:Individual
Prefix:MISS
First Name:SUSAN
Middle Name:DEANN
Last Name:BRUNKE
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:372 CHALFONTE AVE
Mailing Address - Street 2:
Mailing Address - City:GROSSE POINTE FARMS
Mailing Address - State:MI
Mailing Address - Zip Code:48236-2910
Mailing Address - Country:US
Mailing Address - Phone:313-885-6696
Mailing Address - Fax:313-885-6696
Practice Address - Street 1:372 CHALFONTE AVE
Practice Address - Street 2:
Practice Address - City:GROSSE POINTE FARMS
Practice Address - State:MI
Practice Address - Zip Code:48236-2910
Practice Address - Country:US
Practice Address - Phone:313-885-6696
Practice Address - Fax:313-885-6696
Is Sole Proprietor?:Yes
Enumeration Date:2013-12-16
Last Update Date:2013-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704157716163WC0400X, 163WH0200X, 163WM0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WH0200XNursing Service ProvidersRegistered NurseHome Health
No163WC0400XNursing Service ProvidersRegistered NurseCase Management
No163WM0102XNursing Service ProvidersRegistered NurseMaternal Newborn
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4704157716OtherSTATE OF MICHIGAN RN LICENSE