Provider Demographics
NPI:1992231260
Name:BRUEGGERT, VICTORIA
Entity type:Individual
Prefix:
First Name:VICTORIA
Middle Name:
Last Name:BRUEGGERT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1055 CRYSTAL LN
Mailing Address - Street 2:
Mailing Address - City:DIAMOND
Mailing Address - State:IL
Mailing Address - Zip Code:60416-7086
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1 MEDICAL CENTER DR
Practice Address - Street 2:
Practice Address - City:GALENA
Practice Address - State:IL
Practice Address - Zip Code:61036-8118
Practice Address - Country:US
Practice Address - Phone:815-777-1340
Practice Address - Fax:815-776-7265
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-05
Last Update Date:2022-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209015788363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner