Basic Information
| Provider Information | |||||||||
| NPI: | 1689149189 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BRUDERER | ||||||||
| FirstName: | HEATHER | ||||||||
| MiddleName: | ANN | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | CNM | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | RICHMOND | ||||||||
| OtherFirstName: | HEATHER | ||||||||
| OtherMiddleName: | ANN | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | CNM | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 578 N LEAVITT RD | ||||||||
| Address2: | |||||||||
| City: | AMHERST | ||||||||
| State: | OH | ||||||||
| PostalCode: | 440011131 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4409603912 | ||||||||
| FaxNumber: | 4409603913 | ||||||||
| Practice Location | |||||||||
| Address1: | 578 N LEAVITT RD | ||||||||
| Address2: | |||||||||
| City: | AMHERST | ||||||||
| State: | OH | ||||||||
| PostalCode: | 440011131 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4409603912 | ||||||||
| FaxNumber: | 4409603913 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/10/2018 | ||||||||
| LastUpdateDate: | 08/27/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 08/27/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367A00000X | APRN.CNM.019425 | OH | Y | Physician Assistants & Advanced Practice Nursing Providers | Advanced Practice Midwife |
ID Information
| ID | Type | State | Issuer | Description | 0392751 | 05 | OH | MEDICAID |