Provider Demographics
NPI:1447999081
Name:BRUCK, LYDIA ANN (NP)
Entity type:Individual
Prefix:
First Name:LYDIA
Middle Name:ANN
Last Name:BRUCK
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:LYDIA
Other - Middle Name:ANN
Other - Last Name:WEASE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2120 PRAIRIE DR STE 102
Mailing Address - Street 2:
Mailing Address - City:PROSPER
Mailing Address - State:TX
Mailing Address - Zip Code:75078-3818
Mailing Address - Country:US
Mailing Address - Phone:972-544-9455
Mailing Address - Fax:972-544-9465
Practice Address - Street 1:2120 PRAIRIE DR STE 102
Practice Address - Street 2:
Practice Address - City:PROSPER
Practice Address - State:TX
Practice Address - Zip Code:75078-3818
Practice Address - Country:US
Practice Address - Phone:972-544-9455
Practice Address - Fax:972-544-9465
Is Sole Proprietor?:No
Enumeration Date:2022-06-01
Last Update Date:2024-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1069837363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily