Healthcare Provider Details

I. General information

NPI: 1184934960
Provider Name (Legal Business Name): CAROLINE CLARK BRUGGER CRNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/14/2010
Last Update Date: 07/18/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1015 CHESTNUT ST SUITE 1020
PHILADELPHIA PA
19107-4316
US

IV. Provider business mailing address

1015 CHESTNUT ST SUITE 1020
PHILADELPHIA PA
19107-4316
US

V. Phone/Fax

Practice location:
  • Phone: 215-955-7785
  • Fax: 215-955-9362
Mailing address:
  • Phone: 215-955-7785
  • Fax: 215-955-9362

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberSP011551
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberRN626943
License Number StatePA
# 3
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number014280
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: