Provider Demographics
NPI:1689489510
Name:BRUCKMAN, KRISTIN (NP)
Entity type:Individual
Prefix:
First Name:KRISTIN
Middle Name:
Last Name:BRUCKMAN
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4095 BROOKDALE LN UNIT 6
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45440-4187
Mailing Address - Country:US
Mailing Address - Phone:937-361-0192
Mailing Address - Fax:
Practice Address - Street 1:5412 COURSEVIEW DR STE 215
Practice Address - Street 2:
Practice Address - City:MASON
Practice Address - State:OH
Practice Address - Zip Code:45040-2410
Practice Address - Country:US
Practice Address - Phone:513-204-1910
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-02-10
Last Update Date:2025-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHAPRN.CNP.0038456363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health