MEDICARE: MIRIAM BREHMER FNP

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	117972	MO

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	117972	OTHER	MO	LISCENSE

General Provider Information

NPI Number	:	1619179546
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MIRIAM BREHMER FNP

Provider Business Mailing Address
First Line	:	16225 SHADY LANE DR
Second Line	:
City	:	DEXTER
State	:	MO
Zip	:	63841-8693
Country	:	US
Telephone Number	:	573-624-8423
Fax Number	:

Provider Business Practice Location Address
First Line	:	1207 N DOUGLASS ST
Second Line	:
City	:	MALDEN
State	:	MO
Zip	:	63863-1351
Country	:	US
Telephone Number	:	573-276-3884
Fax Number	:

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

Provider Enumeration Date	:	06/04/2007
Last Update Date	:	08/04/2010

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