Basic Information
| Provider Information | |||||||||
| NPI: | 1992231260 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BRUEGGERT | ||||||||
| FirstName: | VICTORIA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1055 CRYSTAL LN | ||||||||
| Address2: | |||||||||
| City: | DIAMOND | ||||||||
| State: | IL | ||||||||
| PostalCode: | 604167086 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 1 MEDICAL CENTER DR | ||||||||
| Address2: | |||||||||
| City: | GALENA | ||||||||
| State: | IL | ||||||||
| PostalCode: | 610368118 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8157771340 | ||||||||
| FaxNumber: | 8157767265 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/05/2017 | ||||||||
| LastUpdateDate: | 10/21/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 10/21/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 209015788 | IL | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
No ID Information.