Healthcare Provider Details

I. General information

NPI: 1154942076
Provider Name (Legal Business Name): PAYTON BRUURSEMA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/01/2020
Last Update Date: 04/04/2023
Certification Date: 04/04/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12263 JAMES ST
HOLLAND MI
49424-8613
US

IV. Provider business mailing address

3300 36TH ST SE
KENTWOOD MI
49512-2810
US

V. Phone/Fax

Practice location:
  • Phone: 616-494-5423
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: