Active NPI
Brooklyn Gunderson
- Athletic Trainer
- Peoria, IL
National Provider Identifier
1477193035
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Athletic Trainer
- License
- 096.005574
- Practice address
- 1501 W Bradley Ave
Peoria, IL 61625-3219 - Phone
- (715) 507-0439
- NPI assigned
- Jan 13, 2020
- Sex
- Female
- Sole proprietor
- Yes
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 2
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Student in an Organized Health Care Education/Training Program | 390200000X | |||
| Athletic Trainer | 2255A2300X | 096.005574 | IL | Primary |
Addresses
Primary practice location
1501 W Bradley Ave
Peoria, IL 61625-3219
Mailing address
5815 N Aspen Wood Dr Apt 5203
Peoria, IL 61615-8429
Phone (715) 507-0439
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Not enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 096.005574 | IL | MD | Athletic Trainer |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1578873600000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1708473600000",
"number": "1477193035",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "5815 N ASPEN WOOD DR APT 5203",
"city": "PEORIA",
"state": "IL",
"postal_code": "616158429",
"telephone_number": "715-507-0439"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "1501 W BRADLEY AVE",
"city": "PEORIA",
"state": "IL",
"postal_code": "616253219",
"telephone_number": "715-507-0439"
}
],
"practiceLocations": [],
"basic": {
"last_name": "GUNDERSON",
"first_name": "BROOKLYN",
"sole_proprietor": "YES",
"sex": "F",
"enumeration_date": "2020-01-13",
"last_updated": "2024-02-21",
"certification_date": "2024-02-21",
"status": "A"
},
"taxonomies": [
{
"code": "390200000X",
"taxonomy_group": "",
"desc": "Student in an Organized Health Care Education/Training Program",
"state": null,
"license": null,
"primary": false
},
{
"code": "2255A2300X",
"taxonomy_group": "",
"desc": "Specialist/Technologist, Athletic Trainer",
"state": "IL",
"license": "096.005574",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Peoria, IL
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Feb 21, 2024; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.