Healthcare Provider Details

I. General information

NPI: 1962461863
Provider Name (Legal Business Name): MARILYN ANNE BRUDERER APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 03/20/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

718 SMYTH RD VA MEDICAL CENTER
MANCHESTER NH
03104-7004
US

IV. Provider business mailing address

177 HOWE ST
METHUEN MA
01844-2128
US

V. Phone/Fax

Practice location:
  • Phone: 603-624-4366
  • Fax: 603-626-6572
Mailing address:
  • Phone: 978-688-5743
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number204393-4405
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: