Provider Demographics
NPI:1366776411
Name:KNOWLTON, BRUCEALYNEA JOY (FNP)
Entity type:Individual
Prefix:
First Name:BRUCEALYNEA
Middle Name:JOY
Last Name:KNOWLTON
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4101 WESLEY ST STE C
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:75401-5635
Mailing Address - Country:US
Mailing Address - Phone:903-454-8111
Mailing Address - Fax:
Practice Address - Street 1:4101 WESLEY ST STE C
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:TX
Practice Address - Zip Code:75401-5635
Practice Address - Country:US
Practice Address - Phone:903-454-8111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-09-22
Last Update Date:2010-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX707126363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX211527103Medicaid
TX211527101Medicaid
TX211527102Medicaid
TX8L26948Medicare PIN
TX211527101Medicaid
TX8L26913Medicare PIN