Healthcare Provider Details

I. General information

NPI: 1215510862
Provider Name (Legal Business Name): HALLI DISBROW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/02/2021
Last Update Date: 03/13/2025
Certification Date: 03/13/2025
Deactivation Date: 11/25/2024
Reactivation Date: 03/07/2025

III. Provider practice location address

3500 LAKE DR SE
GRAND RAPIDS MI
49546-4310
US

IV. Provider business mailing address

3500 LAKE DR SE
GRAND RAPIDS MI
49546-4310
US

V. Phone/Fax

Practice location:
  • Phone: 616-475-7577
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: