Provider Demographics
NPI:1043700909
Name:BRUSCA, MOLLIE RENEE
Entity type:Individual
Prefix:
First Name:MOLLIE
Middle Name:RENEE
Last Name:BRUSCA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MOLLIE
Other - Middle Name:RENEE
Other - Last Name:DONOFF
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:FNP-C
Mailing Address - Street 1:13397 AVENTIDE LN
Mailing Address - Street 2:
Mailing Address - City:ALPHARETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30004-4935
Mailing Address - Country:US
Mailing Address - Phone:937-623-5377
Mailing Address - Fax:
Practice Address - Street 1:550 BETHELVIEW RD
Practice Address - Street 2:
Practice Address - City:CUMMING
Practice Address - State:GA
Practice Address - Zip Code:30040
Practice Address - Country:US
Practice Address - Phone:678-389-6509
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-16
Last Update Date:2018-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN223572363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily