Provider Demographics
NPI:1811649130
Name:BRUIN, MARISSA LYNNE
Entity type:Individual
Prefix:MRS
First Name:MARISSA
Middle Name:LYNNE
Last Name:BRUIN
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 1:19918 CHALON ST
Mailing Address - Street 2:
Mailing Address - City:SAINT CLAIR SHORES
Mailing Address - State:MI
Mailing Address - Zip Code:48080-2226
Mailing Address - Country:US
Mailing Address - Phone:586-909-0360
Mailing Address - Fax:
Practice Address - Street 1:19918 CHALON ST
Practice Address - Street 2:
Practice Address - City:SAINT CLAIR SHORES
Practice Address - State:MI
Practice Address - Zip Code:48080-2226
Practice Address - Country:US
Practice Address - Phone:586-909-0360
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-19
Last Update Date:2024-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704280428363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily