Provider Demographics
NPI:1619678893
Name:BRUCE-LEMMA, KELLY TATIANA
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:TATIANA
Last Name:BRUCE-LEMMA
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 1:3270 WALNUT ST
Mailing Address - Street 2:
Mailing Address - City:COTTONWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:96022-2107
Mailing Address - Country:US
Mailing Address - Phone:530-526-3923
Mailing Address - Fax:
Practice Address - Street 1:3270 WALNUT ST
Practice Address - Street 2:
Practice Address - City:COTTONWOOD
Practice Address - State:CA
Practice Address - Zip Code:96022-2107
Practice Address - Country:US
Practice Address - Phone:530-526-3923
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-14
Last Update Date:2023-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA33795235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist