Provider Demographics
NPI:1336837020
Name:BUSH, BRIANNA MARIE
Entity Type:Individual
Prefix:
First Name:BRIANNA
Middle Name:MARIE
Last Name:BUSH
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 1:2720 BLUE STEM DR
Mailing Address - Street 2:
Mailing Address - City:ZEELAND
Mailing Address - State:MI
Mailing Address - Zip Code:49464-8217
Mailing Address - Country:US
Mailing Address - Phone:317-989-7154
Mailing Address - Fax:
Practice Address - Street 1:2720 BLUE STEM DR
Practice Address - Street 2:
Practice Address - City:ZEELAND
Practice Address - State:MI
Practice Address - Zip Code:49464-8217
Practice Address - Country:US
Practice Address - Phone:317-989-7154
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-01
Last Update Date:2023-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program