Basic Information
| Provider Information | |||||||||
| NPI: | 1881841591 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BRUCE | ||||||||
| FirstName: | KATHRYN | ||||||||
| MiddleName: | MARIE | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | NP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | JANNAUSCH | ||||||||
| OtherFirstName: | KATHRYN | ||||||||
| OtherMiddleName: | MARIE | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | NP | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 38935 ANN ARBOR ROAD | ||||||||
| Address2: | CREDENTIALING/PAYER CONTRACTING SERVICES | ||||||||
| City: | LIVONIA | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481503397 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7346320175 | ||||||||
| FaxNumber: | 7346320182 | ||||||||
| Practice Location | |||||||||
| Address1: | 33155 ANNAPOLIS | ||||||||
| Address2: | EMERGENCY MEDICINE DEPARTMENT | ||||||||
| City: | WANE | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481842405 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7344674042 | ||||||||
| FaxNumber: | 7344675500 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/25/2008 | ||||||||
| LastUpdateDate: | 06/29/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 4704248262 | MI | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363LF0000X | 4704248262 | MI | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 11972106 | 01 | CAQH | OTHER |