Provider Demographics
NPI:1942821079
Name:RANUCCI, BREANNE NICOLE (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:BREANNE
Middle Name:NICOLE
Last Name:RANUCCI
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:BREANNE
Other - Middle Name:NICOLE
Other - Last Name:DIXON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:200 JEFFERSON AVE SE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-4502
Mailing Address - Country:US
Mailing Address - Phone:616-685-5576
Mailing Address - Fax:616-685-8910
Practice Address - Street 1:200 JEFFERSON AVE SE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503-4502
Practice Address - Country:US
Practice Address - Phone:616-685-5576
Practice Address - Fax:616-685-8910
Is Sole Proprietor?:No
Enumeration Date:2020-04-29
Last Update Date:2020-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601009578363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant