Healthcare Provider Details

I. General information

NPI: 1912746405
Provider Name (Legal Business Name): BRIANNA BAILEE BOUWER ATC, MS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/23/2024
Last Update Date: 05/23/2024
Certification Date: 05/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1322 ANDERSON PL NW
GRAND RAPIDS MI
49504-3101
US

IV. Provider business mailing address

1322 ANDERSON PL NW
GRAND RAPIDS MI
49504-3101
US

V. Phone/Fax

Practice location:
  • Phone: 616-414-2835
  • Fax:
Mailing address:
  • Phone: 616-414-2835
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: