Basic Information
| Provider Information | |||||||||
| NPI: | 1114243318 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BRUYERE | ||||||||
| FirstName: | MARIANNE | ||||||||
| MiddleName: | TERESA | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | RN | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | FENNESSY | ||||||||
| OtherFirstName: | MARIANNE | ||||||||
| OtherMiddleName: | TERESA | ||||||||
| OtherNamePrefix: | MRS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | RN | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1 CHIMNEY POINT DR | ||||||||
| Address2: | |||||||||
| City: | OGDENSBURG | ||||||||
| State: | NY | ||||||||
| PostalCode: | 136692212 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3155412001 | ||||||||
| FaxNumber: | 3155412089 | ||||||||
| Practice Location | |||||||||
| Address1: | 1 CHIMNEY POINT DR | ||||||||
| Address2: | |||||||||
| City: | OGDENSBURG | ||||||||
| State: | NY | ||||||||
| PostalCode: | 136692212 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3155412001 | ||||||||
| FaxNumber: | 3155412089 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/13/2010 | ||||||||
| LastUpdateDate: | 04/13/2010 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
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| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163WP0807X | 490645 | NY | Y | Nursing Service Providers | Registered Nurse | Psych/Mental Health, Child & Adolescent |
No ID Information.