Healthcare Provider Details

I. General information

NPI: 1083394167
Provider Name (Legal Business Name): ALEXA DENA BRUCE PA - C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/24/2023
Last Update Date: 05/23/2024
Certification Date: 05/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

326 WASHINGTON STREET
NORWICH CT
06360-4710
US

IV. Provider business mailing address

4492 BLACKLAND DR
MARIETTA GA
30067-4710
US

V. Phone/Fax

Practice location:
  • Phone: 860-889-8331
  • Fax: 860-823-1501
Mailing address:
  • Phone: 678-314-8525
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number6472
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: