Provider Demographics
NPI:1881841591
Name:BRUCE, KATHRYN MARIE (NP)
Entity type:Individual
Prefix:MS
First Name:KATHRYN
Middle Name:MARIE
Last Name:BRUCE
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:KATHRYN
Other - Middle Name:MARIE
Other - Last Name:JANNAUSCH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:38935 ANN ARBOR ROAD
Mailing Address - Street 2:CREDENTIALING/PAYER CONTRACTING SERVICES
Mailing Address - City:LIVONIA
Mailing Address - State:MI
Mailing Address - Zip Code:48150-3397
Mailing Address - Country:US
Mailing Address - Phone:734-632-0175
Mailing Address - Fax:734-632-0182
Practice Address - Street 1:33155 ANNAPOLIS
Practice Address - Street 2:EMERGENCY MEDICINE DEPARTMENT
Practice Address - City:WANE
Practice Address - State:MI
Practice Address - Zip Code:48184-2405
Practice Address - Country:US
Practice Address - Phone:734-467-4042
Practice Address - Fax:734-467-5500
Is Sole Proprietor?:No
Enumeration Date:2008-08-25
Last Update Date:2011-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704248262363L00000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
11972106OtherCAQH