Provider Demographics
NPI:1497039036
Name:BRUSSARD, KATIE LYNNE (ND)
Entity type:Individual
Prefix:DR
First Name:KATIE
Middle Name:LYNNE
Last Name:BRUSSARD
Suffix:
Gender:F
Credentials:ND
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2091 E 1300 S STE 104
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84108-2277
Mailing Address - Country:US
Mailing Address - Phone:801-783-3801
Mailing Address - Fax:833-606-3378
Practice Address - Street 1:2091 E 1300 S STE 104
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84108-2277
Practice Address - Country:US
Practice Address - Phone:801-783-3801
Practice Address - Fax:833-606-3378
Is Sole Proprietor?:No
Enumeration Date:2011-09-30
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WANT60359284175F00000X, 175F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175F00000XOther Service ProvidersNaturopath
Provider Identifiers
StateIdentifier IDID TypeIssuer
WANT60359284OtherNATUROPATHIC PHYSICIAN LICENSE
UT11065179-7100OtherNATUROPATHIC PHYSICIAN LICENSE
UT11065179-7100OtherNATUROPATHIC PHYSICIAN LICENSE