Provider Demographics
NPI:1366151177
Name:BRUDERER, JOANNA LEIGH PHELPS
Entity type:Individual
Prefix:
First Name:JOANNA
Middle Name:LEIGH PHELPS
Last Name:BRUDERER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1658 ST VINCENTS WAY STE 100B
Mailing Address - Street 2:
Mailing Address - City:MIDDLEBURG
Mailing Address - State:FL
Mailing Address - Zip Code:32068-8459
Mailing Address - Country:US
Mailing Address - Phone:904-214-3313
Mailing Address - Fax:904-406-0913
Practice Address - Street 1:1658 ST VINCENTS WAY STE 100B
Practice Address - Street 2:
Practice Address - City:MIDDLEBURG
Practice Address - State:FL
Practice Address - Zip Code:32068-8459
Practice Address - Country:US
Practice Address - Phone:904-214-3313
Practice Address - Fax:904-406-0913
Is Sole Proprietor?:No
Enumeration Date:2022-11-21
Last Update Date:2022-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPTA28925208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation