Healthcare Provider Details

I. General information

NPI: 1407630114
Provider Name (Legal Business Name): CAROLYN A. BRUICH RN, IBCLC, RLC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/23/2023
Last Update Date: 10/16/2023
Certification Date: 10/16/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8201 TEAKWOOD DR
WACO TX
76712-2425
US

IV. Provider business mailing address

539 W COMMERCE ST STE 8429
DALLAS TX
75208-1953
US

V. Phone/Fax

Practice location:
  • Phone: 254-749-2343
  • Fax:
Mailing address:
  • Phone: 254-749-2343
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WL0100X
TaxonomyLactation Consultant (Registered Nurse)
License Number675043
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: