Provider Demographics
NPI:1700307519
Name:BRUBAKER, BRENDA JO (FNP-BC)
Entity Type:Individual
Prefix:
First Name:BRENDA
Middle Name:JO
Last Name:BRUBAKER
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:120 MAPLEWOOD DR
Mailing Address - Street 2:
Mailing Address - City:FAIRMONT
Mailing Address - State:WV
Mailing Address - Zip Code:26554-2162
Mailing Address - Country:US
Mailing Address - Phone:304-612-0365
Mailing Address - Fax:
Practice Address - Street 1:120 MAPLEWOOD DR
Practice Address - Street 2:
Practice Address - City:FAIRMONT
Practice Address - State:WV
Practice Address - Zip Code:26554-2162
Practice Address - Country:US
Practice Address - Phone:304-612-0365
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-30
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVAPRN68184-FNP-BC363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily