Healthcare Provider Details

I. General information

NPI: 1962337352
Provider Name (Legal Business Name): MELISSA BRUCKNER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: MELISSA WAGES

II. Dates (important events)

Enumeration Date: 06/16/2026
Last Update Date: 06/16/2026
Certification Date: 06/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

488 N MAIN ST STE 107
ALPHARETTA GA
30009-8384
US

IV. Provider business mailing address

14361 CLUB CIR
ALPHARETTA GA
30004-4363
US

V. Phone/Fax

Practice location:
  • Phone: 770-250-6000
  • Fax:
Mailing address:
  • Phone: 678-245-2736
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN177305
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: