Provider Demographics
NPI:1235884586
Name:BRUNINK, CAROLYN
Entity Type:Individual
Prefix:
First Name:CAROLYN
Middle Name:
Last Name:BRUNINK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:CAROLYN
Other - Middle Name:
Other - Last Name:BRUNINK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:8710 W HELMS RD
Mailing Address - Street 2:
Mailing Address - City:MC BAIN
Mailing Address - State:MI
Mailing Address - Zip Code:49657-9468
Mailing Address - Country:US
Mailing Address - Phone:231-878-6753
Mailing Address - Fax:
Practice Address - Street 1:8710 W HELMS RD
Practice Address - Street 2:
Practice Address - City:MC BAIN
Practice Address - State:MI
Practice Address - Zip Code:49657-9468
Practice Address - Country:US
Practice Address - Phone:231-878-6753
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-15
Last Update Date:2022-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4703034753164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes164W00000XNursing Service ProvidersLicensed Practical NurseGroup - Single Specialty