Provider Demographics
NPI:1063178820
Name:BRUMBAUGH, IDETTE (RN)
Entity type:Individual
Prefix:MS
First Name:IDETTE
Middle Name:
Last Name:BRUMBAUGH
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30 SHELLDRAKE CT
Mailing Address - Street 2:
Mailing Address - City:DAMASCUS
Mailing Address - State:MD
Mailing Address - Zip Code:20872-2614
Mailing Address - Country:US
Mailing Address - Phone:301-758-0866
Mailing Address - Fax:301-253-5174
Practice Address - Street 1:30 SHELLDRAKE CT
Practice Address - Street 2:
Practice Address - City:DAMASCUS
Practice Address - State:MD
Practice Address - Zip Code:20872-2614
Practice Address - Country:US
Practice Address - Phone:301-758-0866
Practice Address - Fax:301-253-5174
Is Sole Proprietor?:No
Enumeration Date:2021-11-16
Last Update Date:2021-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR107452163WC0400X, 163WC1500X, 163WC1600X, 163WW0000X, 163WH0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WH0200XNursing Service ProvidersRegistered NurseHome Health
No163WC0400XNursing Service ProvidersRegistered NurseCase Management
No163WC1500XNursing Service ProvidersRegistered NurseCommunity Health
No163WC1600XNursing Service ProvidersRegistered NurseContinuing Education/Staff Development
No163WW0000XNursing Service ProvidersRegistered NurseWound Care