Provider Demographics
NPI:1295255693
Name:BRUESTLE, SALLY LYNN (PA)
Entity type:Individual
Prefix:
First Name:SALLY
Middle Name:LYNN
Last Name:BRUESTLE
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:SALLY
Other - Middle Name:LYNN
Other - Last Name:SPITZER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:50 OUTER DR
Mailing Address - Street 2:
Mailing Address - City:SILVER BAY
Mailing Address - State:MN
Mailing Address - Zip Code:55614-1102
Mailing Address - Country:US
Mailing Address - Phone:218-226-4431
Mailing Address - Fax:218-226-4425
Practice Address - Street 1:50 OUTER DR
Practice Address - Street 2:
Practice Address - City:SILVER BAY
Practice Address - State:MN
Practice Address - Zip Code:55614-1102
Practice Address - Country:US
Practice Address - Phone:218-226-4431
Practice Address - Fax:218-226-4425
Is Sole Proprietor?:No
Enumeration Date:2017-06-27
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant