1831207968 NPI number — GINGER LYNN BRASUELL APRN-C

Table of content: CHRISTA OLIVA DOCTOR OF PHARMACY (NPI 1114569662)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1831207968 NPI number — GINGER LYNN BRASUELL APRN-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BRASUELL
Provider First Name:
GINGER
Provider Middle Name:
LYNN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
APRN-C
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
BRASUELL
Provider Other First Name:
GINGER
Provider Other Middle Name:
LYNN
Provider Other Name Prefix Text:
MS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
APRN-C
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1831207968
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/05/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1013 E 19TH ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SCOTTSBLUFF
Provider Business Mailing Address State Name:
NE
Provider Business Mailing Address Postal Code:
69361-2635
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
308-635-0882
Provider Business Mailing Address Fax Number:
308-635-0883

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1013 E 19TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SCOTTSBLUFF
Provider Business Practice Location Address State Name:
NE
Provider Business Practice Location Address Postal Code:
69361-2635
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
308-635-0882
Provider Business Practice Location Address Fax Number:
308-635-0883
Provider Enumeration Date:
08/28/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LP0808X , with the licence number:  110486 , registered in the state of NE ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 100264473-00 , issued by the state of ( NE ) . This identifiers is of the category "MEDICAID".
  • Identifier: 100264472-00 , issued by the state of ( NE ) . This identifiers is of the category "MEDICAID".




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