Healthcare Provider Details

I. General information

NPI: 1376026336
Provider Name (Legal Business Name): AMY RENEE BRODEUR FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/14/2018
Last Update Date: 09/14/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2930 11TH AVE
EVANS CO
80620-1011
US

IV. Provider business mailing address

2930 11TH AVE
EVANS CO
80620-1011
US

V. Phone/Fax

Practice location:
  • Phone: 970-350-4606
  • Fax: 970-350-4645
Mailing address:
  • Phone: 970-350-4606
  • Fax: 970-350-4645

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number994120
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: