Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 363LC1500X | Nurse Practitioner - Community Health | 4704124111 | MI |
NPI | 1447430236 |
---|---|
Provider Name | Brooke Alice Borgeson-Gray |
First Address | Traverse City, MI 49684-4772 |
Second Address | Traverse City, MI 49684-4772 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 08/11/2007 |
Last Update Date | 22/07/2008 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
1447430236 | (05) | MI |