Provider Demographics
NPI:1609203231
Name:BRUSETH, MADGE KATHLEEN (LPN)
Entity Type:Individual
Prefix:MS
First Name:MADGE
Middle Name:KATHLEEN
Last Name:BRUSETH
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3763 EVANS AVE
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33901-9302
Mailing Address - Country:US
Mailing Address - Phone:239-791-1586
Mailing Address - Fax:239-338-2618
Practice Address - Street 1:3763 EVANS AVE
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33901-9302
Practice Address - Country:US
Practice Address - Phone:239-791-1586
Practice Address - Fax:239-338-2618
Is Sole Proprietor?:No
Enumeration Date:2013-09-27
Last Update Date:2013-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPN5191513164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse