Provider Demographics
NPI:1235876178
Name:BRUCH, KELLY ANNE (RN, MSN, CNM)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:ANNE
Last Name:BRUCH
Suffix:
Gender:F
Credentials:RN, MSN, CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:37690 ARBOR WOODS DR
Mailing Address - Street 2:
Mailing Address - City:LIVONIA
Mailing Address - State:MI
Mailing Address - Zip Code:48150-4401
Mailing Address - Country:US
Mailing Address - Phone:313-559-2363
Mailing Address - Fax:
Practice Address - Street 1:37690 ARBOR WOODS DR
Practice Address - Street 2:
Practice Address - City:LIVONIA
Practice Address - State:MI
Practice Address - Zip Code:48150-4401
Practice Address - Country:US
Practice Address - Phone:313-559-2363
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-12
Last Update Date:2024-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704330667163W00000X, 367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
No163W00000XNursing Service ProvidersRegistered Nurse