Provider Demographics
NPI:1114020104
Name:BRUGGEMAN, ALICE ODELIA (NP)
Entity type:Individual
Prefix:
First Name:ALICE
Middle Name:ODELIA
Last Name:BRUGGEMAN
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1200 W WHITE RIVER BLVD
Mailing Address - Street 2:
Mailing Address - City:MUNCIE
Mailing Address - State:IN
Mailing Address - Zip Code:47303-4988
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:428 WEST VOTAW STREET
Practice Address - Street 2:SUITE A
Practice Address - City:PORTLAND
Practice Address - State:IN
Practice Address - Zip Code:47371-0710
Practice Address - Country:US
Practice Address - Phone:260-726-8822
Practice Address - Fax:260-726-7857
Is Sole Proprietor?:No
Enumeration Date:2006-09-06
Last Update Date:2020-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71000942A363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
INM400015943Medicare PIN