Healthcare Provider Details

I. General information

NPI: 1699693614
Provider Name (Legal Business Name): MARISSA BRUNI PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

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

III. Provider practice location address

4100 EMBASSY DR SE STE 400
GRAND RAPIDS MI
49546-2416
US

IV. Provider business mailing address

701 JEROME ST
MIDLAND MI
48640-4981
US

V. Phone/Fax

Practice location:
  • Phone: 248-843-3851
  • Fax:
Mailing address:
  • Phone: 248-843-3851
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number5601014143
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: