Provider Demographics
NPI:1124490594
Name:BRUMAGE, NICOLE L (CRNA)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:L
Last Name:BRUMAGE
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:L
Other - Last Name:SNYDER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CRNA
Mailing Address - Street 1:500 W SUPERIOR ST
Mailing Address - Street 2:UNIT 2009
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60654-8132
Mailing Address - Country:US
Mailing Address - Phone:724-544-8284
Mailing Address - Fax:
Practice Address - Street 1:1959 NE PACIFIC ST
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98195-8132
Practice Address - Country:US
Practice Address - Phone:206-520-5700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-10-26
Last Update Date:2019-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL041.435683163W00000X
IL209013912367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1124490594Medicaid