Provider Demographics
NPI:1275102022
Name:BRUCE, TASHICA (FNP)
Entity Type:Individual
Prefix:MS
First Name:TASHICA
Middle Name:
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 1:3116 W 100TH ST
Mailing Address - Street 2:
Mailing Address - City:EVERGREEN PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60805-3507
Mailing Address - Country:US
Mailing Address - Phone:231-638-3389
Mailing Address - Fax:
Practice Address - Street 1:301 SPRINGFIELD AVE STE 2
Practice Address - Street 2:
Practice Address - City:JOLIET
Practice Address - State:IL
Practice Address - Zip Code:60435-8202
Practice Address - Country:US
Practice Address - Phone:815-630-5119
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-24
Last Update Date:2021-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209.022834363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily