Provider Demographics
NPI:1003342551
Name:PRUSS, KATHERINE (DNP)
Entity Type:Individual
Prefix:DR
First Name:KATHERINE
Middle Name:
Last Name:PRUSS
Suffix:
Gender:F
Credentials:DNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3411 BURTON RIDGE RD SE
Mailing Address - Street 2:APT B
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49546-5834
Mailing Address - Country:US
Mailing Address - Phone:734-223-4562
Mailing Address - Fax:
Practice Address - Street 1:3201 BURTON ST SE
Practice Address - Street 2:SB 260
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49546-4301
Practice Address - Country:US
Practice Address - Phone:616-526-6808
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-03
Last Update Date:2017-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704274169363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily