Provider Demographics
NPI:1154499879
Name:BRUCE, KELLIE E (FNP)
Entity type:Individual
Prefix:
First Name:KELLIE
Middle Name:E
Last Name:BRUCE
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7008 INDIANA AVENUE
Mailing Address - Street 2:SUITE A
Mailing Address - City:LUBBOCK
Mailing Address - State:TX
Mailing Address - Zip Code:79413
Mailing Address - Country:US
Mailing Address - Phone:806-788-1377
Mailing Address - Fax:806-281-1567
Practice Address - Street 1:7008 INDIANA AVENUE
Practice Address - Street 2:SUITE A
Practice Address - City:LUBBOCK
Practice Address - State:TX
Practice Address - Zip Code:79413
Practice Address - Country:US
Practice Address - Phone:806-788-1377
Practice Address - Fax:806-281-1567
Is Sole Proprietor?:No
Enumeration Date:2006-12-01
Last Update Date:2019-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX550481363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX85N746Medicare ID - Type Unspecified
P24846Medicare UPIN