Healthcare Provider Details

I. General information

NPI: 1114551272
Provider Name (Legal Business Name): BRANDY LEE HENRIKSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/27/2020
Last Update Date: 11/07/2024
Certification Date: 11/07/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1521 GULL RD
KALAMAZOO MI
49048-1640
US

IV. Provider business mailing address

6465 E COLONY RD
ELSIE MI
48831-9758
US

V. Phone/Fax

Practice location:
  • Phone: 269-226-7000
  • Fax:
Mailing address:
  • Phone: 989-307-2893
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RC0200X
TaxonomyCritical Care Medicine (Internal Medicine) Physician
License Number4704309996
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number4704309996
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: