Healthcare Provider Details

I. General information

NPI: 1750953477
Provider Name (Legal Business Name): BRYN LOU BRENDAMOUR MSN, APN, FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/13/2021
Last Update Date: 09/06/2022
Certification Date: 09/06/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

123 EMMA RD
BASALT CO
81621-9169
US

IV. Provider business mailing address

747 S GALENA ST UNIT 440
ASPEN CO
81611-1872
US

V. Phone/Fax

Practice location:
  • Phone: 970-945-2840
  • Fax: 970-945-2893
Mailing address:
  • Phone: 513-314-4868
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPN.0996610-NP
License Number StateCO

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: