Provider Demographics
NPI:1255838538
Name:BRISSETTE, AMBER (NP)
Entity Type:Individual
Prefix:
First Name:AMBER
Middle Name:
Last Name:BRISSETTE
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 1:123 LANSING ST STE 3B
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:MI
Mailing Address - Zip Code:48813-1696
Mailing Address - Country:US
Mailing Address - Phone:517-541-5954
Mailing Address - Fax:
Practice Address - Street 1:123 LANSING ST STE 2
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:MI
Practice Address - Zip Code:48813-1696
Practice Address - Country:US
Practice Address - Phone:517-543-9500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-12
Last Update Date:2018-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704265626363LF0000X
MI4704265626NSA18445363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4704265626OtherRN SPECIALTY CERTIFICATION NP