Provider Demographics
NPI:1760844948
Name:BRUCE, CHARLI I
Entity Type:Individual
Prefix:
First Name:CHARLI
Middle Name:
Last Name:BRUCE
Suffix:I
Gender:F
Credentials:
Other - Prefix:
Other - First Name:CHARLI
Other - Middle Name:
Other - Last Name:BRUCE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:CPNP
Mailing Address - Street 1:126 CLINIC DR
Mailing Address - Street 2:
Mailing Address - City:DOTHAN
Mailing Address - State:AL
Mailing Address - Zip Code:36303-1980
Mailing Address - Country:US
Mailing Address - Phone:334-793-1881
Mailing Address - Fax:334-712-1815
Practice Address - Street 1:323 E BARBOUR ST
Practice Address - Street 2:
Practice Address - City:EUFAULA
Practice Address - State:AL
Practice Address - Zip Code:36027-1603
Practice Address - Country:US
Practice Address - Phone:334-619-0940
Practice Address - Fax:334-619-0945
Is Sole Proprietor?:No
Enumeration Date:2016-03-25
Last Update Date:2016-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1-126147363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics