Provider Demographics
NPI:1528595055
Name:BRAUTIGAM, AMBER ROSE
Entity Type:Individual
Prefix:
First Name:AMBER
Middle Name:ROSE
Last Name:BRAUTIGAM
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 1:315 FULLER AVE SE # 2
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49506-1639
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:315 FULLER AVE SE # 2
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49506-1639
Practice Address - Country:US
Practice Address - Phone:231-360-5683
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-05-15
Last Update Date:2017-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner