Provider Demographics
NPI:1982872313
Name:BRUSH, CHARLENE MARIE (ARNP)
Entity Type:Individual
Prefix:
First Name:CHARLENE
Middle Name:MARIE
Last Name:BRUSH
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:CHARLENE
Other - Middle Name:MARIE
Other - Last Name:VANETTEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 1459
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55440-1459
Mailing Address - Country:US
Mailing Address - Phone:478-538-0908
Mailing Address - Fax:
Practice Address - Street 1:9900 BREN RD E
Practice Address - Street 2:
Practice Address - City:MINNETONKA
Practice Address - State:MN
Practice Address - Zip Code:55343-9664
Practice Address - Country:US
Practice Address - Phone:478-538-0908
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-02-19
Last Update Date:2020-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP30007984363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0277902OtherL&I
WA1057235Medicaid
WA1057235Medicaid