MEDICARE: PROF. BRENDA O. DIMAURO C.P.N.P.

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	363L00000X	Nurse Practitioner	P00691	AR

General Provider Information

NPI Number	:	1497704365
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	PROF. BRENDA O. DIMAURO C.P.N.P.

Provider Business Mailing Address
First Line	:	2100 N GREEN ACRES RD
Second Line	:	SUITE A
City	:	FAYETTEVILLE
State	:	AR
Zip	:	72703-2807
Country	:	US
Telephone Number	:	479-521-3363
Fax Number	:	479-521-4167

Provider Business Practice Location Address
First Line	:	2100 N GREEN ACRES RD
Second Line	:	SUITE A
City	:	FAYETTEVILLE
State	:	AR
Zip	:	72703-2807
Country	:	US
Telephone Number	:	479-521-3363
Fax Number	:	479-521-4167

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

Provider Enumeration Date	:	05/09/2006
Last Update Date	:	07/12/2007

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