Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207ND0900X | Dermatopathologist | 046274 | CT |
N | 207ND0900X | Dermatopathologist | 4301079716 | MI |
NPI | 1619909611 |
---|---|
Provider Name | Nicole M. Bossenbroek |
First Address | Norton Shores, MI 49444-7831 |
Second Address | Norton Shores, MI 49444-7831 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 07/07/2006 |
Last Update Date | 16/02/2010 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
I69580 | (02) |