Healthcare Provider Details

I. General information

NPI: 1023699337
Provider Name (Legal Business Name): BRUCINA LIAWATHA MAYFIELD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/19/2021
Last Update Date: 04/19/2021
Certification Date: 04/19/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

385 LEONARD ST NE
GRAND RAPIDS MI
49503-1129
US

IV. Provider business mailing address

385 LEONARD ST NE
GRAND RAPIDS MI
49503-1129
US

V. Phone/Fax

Practice location:
  • Phone: 616-454-4777
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: