Healthcare Provider Details

I. General information

NPI: 1326276395
Provider Name (Legal Business Name): SUSAN A BRUCE CRNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: SUSAN WISE CRNP

II. Dates (important events)

Enumeration Date: 06/29/2009
Last Update Date: 09/28/2021
Certification Date: 09/28/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1315 BURRO AVE
CLOUDCROFT NM
88317-7719
US

IV. Provider business mailing address

PO BOX 1902
CLOUDCROFT NM
88317-1902
US

V. Phone/Fax

Practice location:
  • Phone: 575-682-2002
  • Fax: 575-682-2003
Mailing address:
  • Phone: 575-921-2318
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberCNP02684
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: