Provider Demographics
NPI:1740646421
Name:BRUCE, CHARLES ALLEN (FNP-C)
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:ALLEN
Last Name:BRUCE
Suffix:
Gender:M
Credentials:FNP-C
Other - Prefix:
Other - First Name:AL
Other - Middle Name:
Other - Last Name:BRUCE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:FNP-C
Mailing Address - Street 1:415 S 28TH AVE
Mailing Address - Street 2:
Mailing Address - City:HATTIESBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39401-7246
Mailing Address - Country:US
Mailing Address - Phone:601-758-3100
Mailing Address - Fax:601-579-5240
Practice Address - Street 1:1238 HIGHWAY 42
Practice Address - Street 2:
Practice Address - City:SUMRALL
Practice Address - State:MS
Practice Address - Zip Code:39482-9519
Practice Address - Country:US
Practice Address - Phone:601-758-3100
Practice Address - Fax:601-758-3060
Is Sole Proprietor?:No
Enumeration Date:2016-01-11
Last Update Date:2020-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS901427363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS09931583Medicaid