Provider Demographics
NPI:1962004101
Name:BRUBAKKEN, KATIANNE (PT)
Entity Type:Individual
Prefix:
First Name:KATIANNE
Middle Name:
Last Name:BRUBAKKEN
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PSC 41 BOX 1747
Mailing Address - Street 2:
Mailing Address - City:APO
Mailing Address - State:AE
Mailing Address - Zip Code:09464-0018
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:48TH MEDICAL GROUP
Practice Address - Street 2:UNIT 5115
Practice Address - City:APO
Practice Address - State:AE
Practice Address - Zip Code:09461-5115
Practice Address - Country:US
Practice Address - Phone:314-226-8010
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-12
Last Update Date:2020-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist