Healthcare Provider Details

I. General information

NPI: 1255825691
Provider Name (Legal Business Name): SIERRA MARIE BRUCE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/19/2018
Last Update Date: 11/09/2022
Certification Date: 11/09/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

220 S BREIEL BLVD
MIDDLETOWN OH
45044-5106
US

IV. Provider business mailing address

PO BOX 55
WALTON KY
41094-0055
US

V. Phone/Fax

Practice location:
  • Phone: 513-849-8670
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WA0400X
TaxonomyAddiction (Substance Use Disorder) Registered Nurse
License Number488537
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License Number161537
License Number StateOH
# 3
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number488537
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: