Provider Demographics
NPI:1154793719
Name:BRUCKNER, AMY LOUISE
Entity type:Individual
Prefix:MRS
First Name:AMY
Middle Name:LOUISE
Last Name:BRUCKNER
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 1:29 ULLOM RD
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:PA
Mailing Address - Zip Code:15301-8652
Mailing Address - Country:US
Mailing Address - Phone:724-809-8691
Mailing Address - Fax:
Practice Address - Street 1:155 WILSON AVE
Practice Address - Street 2:WASHINGTON HOSP
Practice Address - City:WASHINGTON
Practice Address - State:PA
Practice Address - Zip Code:15301-3336
Practice Address - Country:US
Practice Address - Phone:800-394-4445
Practice Address - Fax:706-396-3252
Is Sole Proprietor?:No
Enumeration Date:2015-10-22
Last Update Date:2017-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV77260163W00000X
PARN586328163W00000X
PA109363367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse