Provider Demographics
NPI:1447899877
Name:BRUCE, TONYA MARIE (OWNER)
Entity type:Individual
Prefix:MRS
First Name:TONYA
Middle Name:MARIE
Last Name:BRUCE
Suffix:
Gender:F
Credentials:OWNER
Other - Prefix:MR
Other - First Name:DEMETRIUS
Other - Middle Name:SHAWN
Other - Last Name:JOSEPH
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:OWNER
Mailing Address - Street 1:2322 ARNOLD PALMER BLVD
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40245-5272
Mailing Address - Country:US
Mailing Address - Phone:502-773-8783
Mailing Address - Fax:502-412-1405
Practice Address - Street 1:2322 ARNOLD PALMER BLVD
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40245-5272
Practice Address - Country:US
Practice Address - Phone:502-773-8783
Practice Address - Fax:502-412-1405
Is Sole Proprietor?:No
Enumeration Date:2020-01-02
Last Update Date:2020-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYJ95602020172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver