Provider Demographics
NPI:1316541287
Name:BROLSMA, HAVEN SHAYE (CRNP)
Entity Type:Individual
Prefix:
First Name:HAVEN
Middle Name:SHAYE
Last Name:BROLSMA
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2926 COUNTY ROAD 143
Mailing Address - Street 2:
Mailing Address - City:BREMEN
Mailing Address - State:AL
Mailing Address - Zip Code:35033-7031
Mailing Address - Country:US
Mailing Address - Phone:256-590-1502
Mailing Address - Fax:
Practice Address - Street 1:101 IVORY PL
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:AL
Practice Address - Zip Code:35758-2349
Practice Address - Country:US
Practice Address - Phone:256-325-0236
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-22
Last Update Date:2022-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1-157639363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily