Provider Demographics
NPI:1972509339
Name:BRUGGEMANN, AMY (FNP)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:
Last Name:BRUGGEMANN
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 1:2500 EXECUTIVE DRIVE
Mailing Address - Street 2:SUITE 104
Mailing Address - City:ST. CHARLES
Mailing Address - State:MO
Mailing Address - Zip Code:63303
Mailing Address - Country:US
Mailing Address - Phone:888-811-4677
Mailing Address - Fax:800-605-8906
Practice Address - Street 1:40 N 64TH ST
Practice Address - Street 2:
Practice Address - City:BELLEVILLE
Practice Address - State:IL
Practice Address - Zip Code:62223-3808
Practice Address - Country:US
Practice Address - Phone:618-397-8400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-06-21
Last Update Date:2014-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209005238363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILK12127Medicare UPIN
ILK12126Medicare UPIN