Provider Demographics
NPI:1801874268
Name:BOURZAC, SHERYL SUE (FNP)
Entity type:Individual
Prefix:
First Name:SHERYL
Middle Name:SUE
Last Name:BOURZAC
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:96 E 120TH ST
Mailing Address - Street 2:
Mailing Address - City:GRANT
Mailing Address - State:MI
Mailing Address - Zip Code:49327-8502
Mailing Address - Country:US
Mailing Address - Phone:231-834-0444
Mailing Address - Fax:231-834-0200
Practice Address - Street 1:96 E 120TH ST
Practice Address - Street 2:
Practice Address - City:GRANT
Practice Address - State:MI
Practice Address - Zip Code:49327-8502
Practice Address - Country:US
Practice Address - Phone:231-834-0444
Practice Address - Fax:231-834-0200
Is Sole Proprietor?:No
Enumeration Date:2006-01-05
Last Update Date:2013-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71002015A363LF0000X
MI4704180870363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200801560Medicaid
INQ59308Medicare UPIN
IN178410XXMedicare ID - Type Unspecified
IN178420VMedicare ID - Type Unspecified