Provider Demographics
NPI:1124671409
Name:BRUCE, COURTNEY
Entity type:Individual
Prefix:
First Name:COURTNEY
Middle Name:
Last Name:BRUCE
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 1:2304 HICKORY CREEK DR APT 5A
Mailing Address - Street 2:
Mailing Address - City:HENRICO
Mailing Address - State:VA
Mailing Address - Zip Code:23294-8824
Mailing Address - Country:US
Mailing Address - Phone:126-249-8956
Mailing Address - Fax:
Practice Address - Street 1:2304 HICKORY CREEK DR APT 5A
Practice Address - Street 2:
Practice Address - City:HENRICO
Practice Address - State:VA
Practice Address - Zip Code:23294-8824
Practice Address - Country:US
Practice Address - Phone:262-498-9569
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-16
Last Update Date:2019-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA374U00000X
253Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes253Z00000XAgenciesIn Home Supportive CareGroup - Single Specialty
No374U00000XNursing Service Related ProvidersHome Health AideGroup - Single Specialty