Healthcare Provider Details

I. General information

NPI: 1619909611
Provider Name (Legal Business Name): NICOLE M. BOSSENBROEK M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/07/2006
Last Update Date: 07/25/2026
Certification Date: 07/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6735 CASCADE RD SE STE 300
GRAND RAPIDS MI
49546-8705
US

IV. Provider business mailing address

6735 CASCADE RD SE STE 300
GRAND RAPIDS MI
49546-8705
US

V. Phone/Fax

Practice location:
  • Phone: 269-321-7546
  • Fax: 269-321-1705
Mailing address:
  • Phone: 269-321-7546
  • Fax: 269-321-1705

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207ND0900X
TaxonomyDermatopathology Physician
License Number4301079716
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: