Provider Demographics
NPI:1194599894
Name:JASA-BRUDER, CORRIE LYNN (APRN)
Entity type:Individual
Prefix:
First Name:CORRIE
Middle Name:LYNN
Last Name:JASA-BRUDER
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:CORRIE
Other - Middle Name:LYNN
Other - Last Name:WILCOX
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2168 N GLENNFIELD WAY
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83646-1282
Mailing Address - Country:US
Mailing Address - Phone:208-615-0639
Mailing Address - Fax:
Practice Address - Street 1:7101 NEWPORT AVE
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68152-2164
Practice Address - Country:US
Practice Address - Phone:208-615-0639
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-11-13
Last Update Date:2023-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID78033363LP0808X
NE115092363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health