Healthcare Provider Details

I. General information

NPI: 1770122202
Provider Name (Legal Business Name): VANESSA PATRICIA BRUCE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/01/2020
Last Update Date: 01/01/2020
Certification Date: 01/01/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

424 PLAYFUL MEADOWS DR NE
RIO RANCHO NM
87144-4121
US

IV. Provider business mailing address

424 PLAYFUL MEADOWS DR NE
RIO RANCHO NM
87144-4121
US

V. Phone/Fax

Practice location:
  • Phone: 609-977-9809
  • Fax: 505-212-0225
Mailing address:
  • Phone: 609-977-9809
  • Fax: 505-212-0225

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: