Provider Demographics
NPI:1104602226
Name:BRUCKER, LAUREN KELLY
Entity type:Individual
Prefix:
First Name:LAUREN
Middle Name:KELLY
Last Name:BRUCKER
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 1:126 FRONT ST
Mailing Address - Street 2:
Mailing Address - City:SANTA CRUZ
Mailing Address - State:CA
Mailing Address - Zip Code:95060-4402
Mailing Address - Country:US
Mailing Address - Phone:831-427-3387
Mailing Address - Fax:
Practice Address - Street 1:126 FRONT ST
Practice Address - Street 2:
Practice Address - City:SANTA CRUZ
Practice Address - State:CA
Practice Address - Zip Code:95060-4402
Practice Address - Country:US
Practice Address - Phone:831-427-3387
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-09-05
Last Update Date:2023-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker