Basic Information
| Provider Information | |||||||||
| NPI: | 1427489822 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BRUCKER | ||||||||
| FirstName: | KATRINA | ||||||||
| MiddleName: | LIN | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 12 | ||||||||
| Address2: | |||||||||
| City: | LIBERTY LAKE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 990190012 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8667472455 | ||||||||
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| Practice Location | |||||||||
| Address1: | 902 N ORANGE ST STE 202 | ||||||||
| Address2: | |||||||||
| City: | MISSOULA | ||||||||
| State: | MT | ||||||||
| PostalCode: | 598022928 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4063273362 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/10/2013 | ||||||||
| LastUpdateDate: | 04/02/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/02/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 5618-33 | WI | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363LP0808X | NUR-APRN-LIC-157587 | MT | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health |
No ID Information.