Provider Demographics
NPI:1447430236
Name:BORGESON-GRAY, BROOKE ALICE (NP)
Entity type:Individual
Prefix:
First Name:BROOKE
Middle Name:ALICE
Last Name:BORGESON-GRAY
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3147 LOGAN VALLEY RD
Mailing Address - Street 2:
Mailing Address - City:TRAVERSE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49684-4772
Mailing Address - Country:US
Mailing Address - Phone:231-929-3111
Mailing Address - Fax:231-946-0445
Practice Address - Street 1:3147 LOGAN VALLEY RD
Practice Address - Street 2:
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49684-4772
Practice Address - Country:US
Practice Address - Phone:231-929-3111
Practice Address - Fax:231-946-0445
Is Sole Proprietor?:No
Enumeration Date:2007-11-08
Last Update Date:2008-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704124111363LC1500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LC1500XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerCommunity Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1447430236Medicaid