=====================================================
General NPI Number Information
=====================================================
NPI Number | 1760844948
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CHARLI BRUCE I
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/25/2016
-----------------------------------------------------
Last Update Date | 03/25/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 323 E BARBOUR ST
-----------------------------------------------------
City | EUFAULA
-----------------------------------------------------
State | AL
-----------------------------------------------------
Zip | 36027-1603
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 334-619-0940
-----------------------------------------------------
Fax | 334-619-0945
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 126 CLINIC DR
-----------------------------------------------------
City | DOTHAN
-----------------------------------------------------
State | AL
-----------------------------------------------------
Zip | 36303-1980
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 334-793-1881
-----------------------------------------------------
Fax | 334-712-1815
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LP0200X
-----------------------------------------------------
Taxonomy Name | Pediatric Nurse Practitioner
-----------------------------------------------------
License Number | 1-126147
-----------------------------------------------------
License Number State | AL
-----------------------------------------------------