Provider Demographics
NPI:1346379294
Name:BRUMBAUGH, MARLO ANN (REGISTERED NURSE)
Entity Type:Individual
Prefix:MRS
First Name:MARLO
Middle Name:ANN
Last Name:BRUMBAUGH
Suffix:
Gender:F
Credentials:REGISTERED NURSE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:65 BAYLOR ST
Mailing Address - Street 2:
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81005-1610
Mailing Address - Country:US
Mailing Address - Phone:719-566-7878
Mailing Address - Fax:
Practice Address - Street 1:65 BAYLOR ST
Practice Address - Street 2:
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81005-1610
Practice Address - Country:US
Practice Address - Phone:719-566-7878
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO121408163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO58674845Medicaid