Healthcare Provider Details

I. General information

NPI: 1124041504
Provider Name (Legal Business Name): DIANE RUTH BRUDER CNS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/25/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2000 KLEIN STREET
ST. PETER MN
56082
US

IV. Provider business mailing address

2000 KLEIN SSTREET
ST. PETER MN
56082
US

V. Phone/Fax

Practice location:
  • Phone: 507-931-7192
  • Fax:
Mailing address:
  • Phone: 507-931-7192
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberR 102741-9
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: