MEDICARE: MIRIAM LOUISE BRAWLEY FNP-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LF0000X	Family Nurse Practitioner	2017015433	MO
2	363LF0000X	Family Nurse Practitioner	2006007575	MO

General Provider Information

NPI Number	:	1033646187
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MIRIAM LOUISE BRAWLEY FNP-C

Provider Business Mailing Address
First Line	:	1050 W 10TH ST
Second Line	:	ATTN: EXECUTIVE DIRECTOR OF PHYSICIAN CLINICS
City	:	ROLLA
State	:	MO
Zip	:	65401
Country	:	US
Telephone Number	:	573-364-9000
Fax Number	:

Provider Business Practice Location Address
First Line	:	1415 W SCENIC RIVERS BLVD
Second Line	:
City	:	SALEM
State	:	MO
Zip	:	65560-2840
Country	:	US
Telephone Number	:	573-729-5533
Fax Number	:	573-202-2466

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/20/2017
Last Update Date	:	06/06/2022

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