Provider Demographics
NPI:1922652429
Name:PRUNCHAK, KRISTIN JOLENE (PTA)
Entity Type:Individual
Prefix:
First Name:KRISTIN
Middle Name:JOLENE
Last Name:PRUNCHAK
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:KRISTIN
Other - Middle Name:JOLENE
Other - Last Name:BRIMEYER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3399 SUNNY HILL DR
Mailing Address - Street 2:
Mailing Address - City:BETTENDORF
Mailing Address - State:IA
Mailing Address - Zip Code:52722-2316
Mailing Address - Country:US
Mailing Address - Phone:563-343-8924
Mailing Address - Fax:
Practice Address - Street 1:4130 NORTHWEST BLVD
Practice Address - Street 2:
Practice Address - City:DAVENPORT
Practice Address - State:IA
Practice Address - Zip Code:52806-4243
Practice Address - Country:US
Practice Address - Phone:563-388-3291
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-01
Last Update Date:2019-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IANONEOtherNONE OBTAINED