Provider Demographics
NPI:1619909611
Name:BOSSENBROEK, NICOLE M (MD)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:M
Last Name:BOSSENBROEK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6225 PRAIRIE ST
Mailing Address - Street 2:
Mailing Address - City:NORTON SHORES
Mailing Address - State:MI
Mailing Address - Zip Code:49444-7831
Mailing Address - Country:US
Mailing Address - Phone:231-798-9500
Mailing Address - Fax:231-798-9533
Practice Address - Street 1:6225 PRAIRIE ST
Practice Address - Street 2:
Practice Address - City:NORTON SHORES
Practice Address - State:MI
Practice Address - Zip Code:49444-7831
Practice Address - Country:US
Practice Address - Phone:231-798-9500
Practice Address - Fax:231-798-9533
Is Sole Proprietor?:No
Enumeration Date:2006-07-07
Last Update Date:2010-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT046274207ND0900X
MI4301079716207ND0900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ND0900XAllopathic & Osteopathic PhysiciansDermatologyDermatopathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
I69580Medicare UPIN