Basic Information
| Provider Information | |||||||||
| NPI: | 1114314093 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BRO | ||||||||
| FirstName: | AMY | ||||||||
| MiddleName: | JOY | ||||||||
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| Credential: | CNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4000 28TH AVE S | ||||||||
| Address2: | |||||||||
| City: | MOORHEAD | ||||||||
| State: | MN | ||||||||
| PostalCode: | 565607926 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7012343200 | ||||||||
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| Practice Location | |||||||||
| Address1: | 4000 28TH AVE S | ||||||||
| Address2: | |||||||||
| City: | MOORHEAD | ||||||||
| State: | MN | ||||||||
| PostalCode: | 565607926 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7012343200 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/19/2015 | ||||||||
| LastUpdateDate: | 04/19/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | R191121-1 | MN | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363L00000X | R33406 | ND | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | R191121-1 | 01 | MN | REGISTERED NURSE LICENSE | OTHER | R33406 | 01 | ND | REGISTERED NURSE LICENSE | OTHER |