Healthcare Provider Details

I. General information

NPI: 1437522794
Provider Name (Legal Business Name): CONNIE BRUCH-HARRISON PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/09/2015
Last Update Date: 11/09/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1232 E BROADWAY RD SUITE 205
TEMPE AZ
85282-1511
US

IV. Provider business mailing address

PO BOX 7387
TEMPE AZ
85281-0013
US

V. Phone/Fax

Practice location:
  • Phone: 480-874-7014
  • Fax: 480-874-7015
Mailing address:
  • Phone: 480-874-7014
  • Fax: 480-874-7015

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberCRNA1013
License Number StateAZ

VIII. Authorized Official

Name: MRS. GINA HENDERSON
Title or Position: MANAGER
Credential:
Phone: 480-874-7014