Provider Demographics
NPI:1457982522
Name:BRUCE, THALIA LEBOGANG
Entity Type:Individual
Prefix:
First Name:THALIA
Middle Name:LEBOGANG
Last Name:BRUCE
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 1:5519 BONNER AVE APT 2
Mailing Address - Street 2:
Mailing Address - City:NORTH HOLLYWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:91601-5723
Mailing Address - Country:US
Mailing Address - Phone:661-993-8542
Mailing Address - Fax:
Practice Address - Street 1:5519 BONNER AVE APT 2
Practice Address - Street 2:
Practice Address - City:NORTH HOLLYWOOD
Practice Address - State:CA
Practice Address - Zip Code:91601-5723
Practice Address - Country:US
Practice Address - Phone:661-993-8542
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-28
Last Update Date:2020-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95192120163W00000X
253J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes253J00000XAgenciesFoster Care Agency
No163W00000XNursing Service ProvidersRegistered NurseGroup - Multi-Specialty