Healthcare Provider Details

I. General information

NPI: 1275083792
Provider Name (Legal Business Name): BRENDA KRUGER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/07/2016
Last Update Date: 07/05/2022
Certification Date: 07/05/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

37594 HOUSTON ST
LUCERNE VALLEY CA
92356-7983
US

IV. Provider business mailing address

37594 HOUSTON ST
LUCERNE VALLEY CA
92356-7983
US

V. Phone/Fax

Practice location:
  • Phone: 760-265-0971
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number456944
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code163WC0200X
TaxonomyCritical Care Medicine Registered Nurse
License Number456944
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: