Provider Demographics
NPI:1023254018
Name:BRUCKER, PAMELA SUE (LPN)
Entity type:Individual
Prefix:MRS
First Name:PAMELA
Middle Name:SUE
Last Name:BRUCKER
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:W 7755 CTY. RD. V
Mailing Address - Street 2:
Mailing Address - City:CASCADE
Mailing Address - State:WI
Mailing Address - Zip Code:53011-1234
Mailing Address - Country:US
Mailing Address - Phone:920-528-8198
Mailing Address - Fax:920-528-7056
Practice Address - Street 1:W7755 CTY RD V
Practice Address - Street 2:
Practice Address - City:CASCADE
Practice Address - State:WI
Practice Address - Zip Code:53011-1234
Practice Address - Country:US
Practice Address - Phone:920-528-8198
Practice Address - Fax:920-528-7056
Is Sole Proprietor?:Yes
Enumeration Date:2008-12-23
Last Update Date:2008-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI14165-031164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse