Provider Demographics
NPI:1073148201
Name:BRULE, NICHOLAS ROBERT
Entity Type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:ROBERT
Last Name:BRULE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:601 MICHIGAN ST NE APT 402
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-3597
Mailing Address - Country:US
Mailing Address - Phone:906-221-1088
Mailing Address - Fax:
Practice Address - Street 1:15 MICHIGAN ST NE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503-2508
Practice Address - Country:US
Practice Address - Phone:906-221-1088
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-09
Last Update Date:2020-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program