Provider Demographics
NPI:1114243318
Name:BRUYERE, MARIANNE TERESA (RN)
Entity Type:Individual
Prefix:MRS
First Name:MARIANNE
Middle Name:TERESA
Last Name:BRUYERE
Suffix:
Gender:F
Credentials:RN
Other - Prefix:MRS
Other - First Name:MARIANNE
Other - Middle Name:TERESA
Other - Last Name:FENNESSY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:1 CHIMNEY POINT DR
Mailing Address - Street 2:
Mailing Address - City:OGDENSBURG
Mailing Address - State:NY
Mailing Address - Zip Code:13669-2212
Mailing Address - Country:US
Mailing Address - Phone:315-541-2001
Mailing Address - Fax:315-541-2089
Practice Address - Street 1:1 CHIMNEY POINT DR
Practice Address - Street 2:
Practice Address - City:OGDENSBURG
Practice Address - State:NY
Practice Address - Zip Code:13669-2212
Practice Address - Country:US
Practice Address - Phone:315-541-2001
Practice Address - Fax:315-541-2089
Is Sole Proprietor?:No
Enumeration Date:2010-04-13
Last Update Date:2010-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY490645163WP0807X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP0807XNursing Service ProvidersRegistered NursePsychiatric/Mental Health, Child & Adolescent