Healthcare Provider Details

I. General information

NPI: 1386205151
Provider Name (Legal Business Name): ANGELA BROUCKAERT FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: ANGELA BROUCKAERT FNP

II. Dates (important events)

Enumeration Date: 06/24/2019
Last Update Date: 08/25/2026
Certification Date: 08/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

44344 DEQUINDRE RD STE 560
STERLING HEIGHTS MI
48314-1043
US

IV. Provider business mailing address

26901 BEAUMONT BLVD STE 3D
SOUTHFIELD MI
48033-3849
US

V. Phone/Fax

Practice location:
  • Phone: 947-523-4590
  • Fax:
Mailing address:
  • Phone: 947-522-1865
  • Fax: 947-522-0307

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number4704309689
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number19072180332
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: