Provider Demographics
NPI:1861137416
Name:BRUDER, DEBORA (RN)
Entity type:Individual
Prefix:
First Name:DEBORA
Middle Name:
Last Name:BRUDER
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:DEBORA
Other - Middle Name:JEAN
Other - Last Name:LA GUARDIA
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:RN
Mailing Address - Street 1:300 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:SMITHTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:11787-2611
Mailing Address - Country:US
Mailing Address - Phone:631-549-9500
Mailing Address - Fax:
Practice Address - Street 1:300 W MAIN ST
Practice Address - Street 2:
Practice Address - City:SMITHTOWN
Practice Address - State:NY
Practice Address - Zip Code:11787-2611
Practice Address - Country:US
Practice Address - Phone:631-549-9500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-28
Last Update Date:2022-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY423403163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse