Provider Demographics
NPI:1861362824
Name:STAFFORD, BROOKELYN MIKELLE
Entity type:Individual
Prefix:
First Name:BROOKELYN
Middle Name:MIKELLE
Last Name:STAFFORD
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 1:4045 WOODLAND CREEK DR SE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49512-8356
Mailing Address - Country:US
Mailing Address - Phone:616-866-6859
Mailing Address - Fax:616-866-6897
Practice Address - Street 1:521 E DIVISION ST
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:MI
Practice Address - Zip Code:49341-1376
Practice Address - Country:US
Practice Address - Phone:616-866-6859
Practice Address - Fax:616-866-6897
Is Sole Proprietor?:No
Enumeration Date:2025-11-06
Last Update Date:2025-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501304183225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist