Provider Demographics
NPI:1871814509
Name:BRUEGGESTRAT, CARLY (CRNA)
Entity type:Individual
Prefix:
First Name:CARLY
Middle Name:
Last Name:BRUEGGESTRAT
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7365 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:STRATFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06614-1300
Mailing Address - Country:US
Mailing Address - Phone:203-384-3174
Mailing Address - Fax:203-384-4619
Practice Address - Street 1:7365 MAIN ST
Practice Address - Street 2:
Practice Address - City:STRATFORD
Practice Address - State:CT
Practice Address - Zip Code:06614-1300
Practice Address - Country:US
Practice Address - Phone:203-384-3174
Practice Address - Fax:203-384-4619
Is Sole Proprietor?:No
Enumeration Date:2010-06-16
Last Update Date:2010-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT074163163W00000X
CT0044440367H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367H00000XPhysician Assistants & Advanced Practice Nursing ProvidersAnesthesiologist Assistant
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTD400022025Medicare PIN