Provider Demographics
NPI:1215571476
Name:BRUCE, KIMBERLY MARIE
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:MARIE
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:PO BOX 305
Mailing Address - Street 2:
Mailing Address - City:WILLARD
Mailing Address - State:MO
Mailing Address - Zip Code:65781-0305
Mailing Address - Country:US
Mailing Address - Phone:417-742-2617
Mailing Address - Fax:417-742-6887
Practice Address - Street 1:128 GRAND PRAIRIE DR
Practice Address - Street 2:
Practice Address - City:WILLARD
Practice Address - State:MO
Practice Address - Zip Code:65781-9773
Practice Address - Country:US
Practice Address - Phone:417-742-2617
Practice Address - Fax:417-742-6887
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-31
Last Update Date:2021-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2019039647111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor