Provider Demographics
NPI:1124041504
Name:BRUDER, DIANE RUTH (CNS)
Entity Type:Individual
Prefix:MISS
First Name:DIANE
Middle Name:RUTH
Last Name:BRUDER
Suffix:
Gender:F
Credentials:CNS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2000 KLEIN SSTREET
Mailing Address - Street 2:
Mailing Address - City:ST. PETER
Mailing Address - State:MN
Mailing Address - Zip Code:56082
Mailing Address - Country:US
Mailing Address - Phone:507-931-7192
Mailing Address - Fax:
Practice Address - Street 1:2000 KLEIN STREET
Practice Address - Street 2:
Practice Address - City:ST. PETER
Practice Address - State:MN
Practice Address - Zip Code:56082
Practice Address - Country:US
Practice Address - Phone:507-931-7192
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR 102741-9363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNP64141Medicare UPIN