Healthcare Provider Details

I. General information

NPI: 1558919845
Provider Name (Legal Business Name): MONIQUE BRUTON FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/29/2019
Last Update Date: 07/08/2021
Certification Date: 07/08/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7131 LIBERTY RD
GWYNN OAK MD
21207-4575
US

IV. Provider business mailing address

415 CRAIN HWY S
GLEN BURNIE MD
21061-3644
US

V. Phone/Fax

Practice location:
  • Phone: 443-985-0369
  • Fax:
Mailing address:
  • Phone: 443-985-0369
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberR185902
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberR185902
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: