Healthcare Provider Details

I. General information

NPI: 1548607948
Provider Name (Legal Business Name): ABIGAIL EMILY FAIRLIE BRUCE MS, ANP-BC, RN, PHN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: ABIGAIL FAIRLIE BRUCE CARVALHO NP

II. Dates (important events)

Enumeration Date: 05/27/2013
Last Update Date: 06/16/2022
Certification Date: 08/23/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

66 TERRACE AVENUE
BOLINAS CA
94924-0683
US

IV. Provider business mailing address

PO BOX 683
BOLINAS CA
94924-0683
US

V. Phone/Fax

Practice location:
  • Phone: 415-987-6542
  • Fax: 888-897-6505
Mailing address:
  • Phone: 415-987-6542
  • Fax: 888-897-6505

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WC1500X
TaxonomyCommunity Health Registered Nurse
License Number802370
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code171400000X
TaxonomyHealth & Wellness Coach
License Number
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number23366
License Number StateCA
# 4
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number23366
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: