Provider Demographics
NPI:1710208624
Name:BRUCKLER, STACEY (CRNA)
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:
Last Name:BRUCKLER
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:STACEY
Other - Middle Name:I
Other - Last Name:LESKY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 844658
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75284-4658
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2401 S 31ST ST
Practice Address - Street 2:
Practice Address - City:TEMPLE
Practice Address - State:TX
Practice Address - Zip Code:76508-1248
Practice Address - Country:US
Practice Address - Phone:254-724-2111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-06-15
Last Update Date:2022-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH082374-23367500000X
FLARNP9162361367500000X
TXAP121712367500000X
TX816543367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLPENDINGMedicaid
FLPENDINGOtherBCBS
FLPENDINGMedicare PIN