Provider Demographics
NPI:1447781984
Name:BUSHNELL, CYNTHIA
Entity Type:Individual
Prefix:
First Name:CYNTHIA
Middle Name:
Last Name:BUSHNELL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2845 LEONARD ST NE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49525-5826
Mailing Address - Country:US
Mailing Address - Phone:616-949-0859
Mailing Address - Fax:616-949-0859
Practice Address - Street 1:2845 LEONARD ST NE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49525-5826
Practice Address - Country:US
Practice Address - Phone:616-949-0859
Practice Address - Fax:616-949-0859
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-26
Last Update Date:2017-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIAF410269952311ZA0620X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home