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General NPI Number Information
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NPI Number | 1720196165
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Entity Type | Individual
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Provider Name | BRUCE DOUGLAS CLYNE CRNP
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Gender | Male
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Dates
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Enumeration Date | 08/27/2006
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Last Update Date | 07/11/2007
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Provider Practice Location Address
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Address Line | 1310 13TH AVENUE VA CLINIC
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City | COLUMBUS
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State | GA
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Zip | 31902
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Country | US
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Telephone | 706-257-7200
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Fax | 706-653-6645
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Provider Business Mailing Address
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Address Line | 62 STILLWATERS GROVE
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City | DADEVILLE
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State | AL
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Zip | 36853
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Country | US
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Telephone | 256-625-9206
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Fax | 706-653-6645
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363L00000X
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Taxonomy Name | Nurse Practitioner
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License Number | 1-077041
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License Number State | AL
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