Provider Demographics
NPI:1326276395
Name:BRUCE, SUSAN A (CRNP)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:A
Last Name:BRUCE
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:SUSAN
Other - Middle Name:
Other - Last Name:WISE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CRNP
Mailing Address - Street 1:PO BOX 1902
Mailing Address - Street 2:
Mailing Address - City:CLOUDCROFT
Mailing Address - State:NM
Mailing Address - Zip Code:88317-1902
Mailing Address - Country:US
Mailing Address - Phone:575-921-2318
Mailing Address - Fax:
Practice Address - Street 1:1315 BURRO AVE
Practice Address - Street 2:
Practice Address - City:CLOUDCROFT
Practice Address - State:NM
Practice Address - Zip Code:88317-7719
Practice Address - Country:US
Practice Address - Phone:575-682-2002
Practice Address - Fax:575-682-2003
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-29
Last Update Date:2021-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMCNP02684363L00000X
MDR169421363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Single Specialty
No363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM99120330Medicaid
MD025174700Medicaid