Provider Demographics
NPI:1114579075
Name:BRUNGARD, VICKI ELLEN (PTA)
Entity type:Individual
Prefix:MRS
First Name:VICKI
Middle Name:ELLEN
Last Name:BRUNGARD
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:831 MILL RD
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSPORT
Mailing Address - State:PA
Mailing Address - Zip Code:17702-8122
Mailing Address - Country:US
Mailing Address - Phone:570-419-6316
Mailing Address - Fax:
Practice Address - Street 1:1705 WARREN AVE STE 102
Practice Address - Street 2:
Practice Address - City:WILLIAMSPORT
Practice Address - State:PA
Practice Address - Zip Code:17701
Practice Address - Country:US
Practice Address - Phone:570-320-7470
Practice Address - Fax:570-320-7471
Is Sole Proprietor?:No
Enumeration Date:2019-07-11
Last Update Date:2019-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PATE1001946225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant