Provider Demographics
NPI:1447398789
Name:DEGRUISE, BRANDI BORNE (FNP)
Entity Type:Individual
Prefix:
First Name:BRANDI
Middle Name:BORNE
Last Name:DEGRUISE
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1094
Mailing Address - Street 2:
Mailing Address - City:HOUMA
Mailing Address - State:LA
Mailing Address - Zip Code:70361-1094
Mailing Address - Country:US
Mailing Address - Phone:985-209-1444
Mailing Address - Fax:985-346-0836
Practice Address - Street 1:1022 BELANGER ST
Practice Address - Street 2:
Practice Address - City:HOUMA
Practice Address - State:LA
Practice Address - Zip Code:70360-4412
Practice Address - Country:US
Practice Address - Phone:985-223-3132
Practice Address - Fax:985-346-0836
Is Sole Proprietor?:No
Enumeration Date:2007-02-01
Last Update Date:2022-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LARN102495-AP05149363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1004154Medicaid
LAQ76945Medicare UPIN
LA3A129Medicare PIN