Provider Demographics
NPI:1114314093
Name:BRO, AMY JOY (CNP)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:JOY
Last Name:BRO
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4000 28TH AVE S
Mailing Address - Street 2:
Mailing Address - City:MOORHEAD
Mailing Address - State:MN
Mailing Address - Zip Code:56560-7926
Mailing Address - Country:US
Mailing Address - Phone:701-234-3200
Mailing Address - Fax:
Practice Address - Street 1:4000 28TH AVE S
Practice Address - Street 2:
Practice Address - City:MOORHEAD
Practice Address - State:MN
Practice Address - Zip Code:56560-7926
Practice Address - Country:US
Practice Address - Phone:701-234-3200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-04-19
Last Update Date:2015-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR191121-1363L00000X
NDR33406363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNR191121-1OtherREGISTERED NURSE LICENSE
NDR33406OtherREGISTERED NURSE LICENSE