Provider Demographics
NPI:1497704365
Name:DIMAURO, BRENDA O (CPNP)
Entity Type:Individual
Prefix:PROF
First Name:BRENDA
Middle Name:O
Last Name:DIMAURO
Suffix:
Gender:F
Credentials:CPNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2100 N GREEN ACRES RD
Mailing Address - Street 2:SUITE A
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72703-2807
Mailing Address - Country:US
Mailing Address - Phone:479-521-3363
Mailing Address - Fax:479-521-4167
Practice Address - Street 1:2100 N GREEN ACRES RD
Practice Address - Street 2:SUITE A
Practice Address - City:FAYETTEVILLE
Practice Address - State:AR
Practice Address - Zip Code:72703-2807
Practice Address - Country:US
Practice Address - Phone:479-521-3363
Practice Address - Fax:479-521-4167
Is Sole Proprietor?:No
Enumeration Date:2006-05-09
Last Update Date:2007-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARP00691363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
ARP12604Medicare UPIN
AR5U795Medicare ID - Type UnspecifiedMEDICARE PROV #