Provider Demographics
NPI:1609678648
Name:BAUSANO, GINA MICHELLE
Entity type:Individual
Prefix:MRS
First Name:GINA
Middle Name:MICHELLE
Last Name:BAUSANO
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11955 RAINTREE CT
Mailing Address - Street 2:
Mailing Address - City:SHELBY TOWNSHIP
Mailing Address - State:MI
Mailing Address - Zip Code:48315-1159
Mailing Address - Country:US
Mailing Address - Phone:586-918-1377
Mailing Address - Fax:
Practice Address - Street 1:11955 RAINTREE CT
Practice Address - Street 2:
Practice Address - City:SHELBY TOWNSHIP
Practice Address - State:MI
Practice Address - Zip Code:48315-1159
Practice Address - Country:US
Practice Address - Phone:586-918-1377
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-03-27
Last Update Date:2025-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIL-316882174N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174N00000XOther Service ProvidersLactation Consultant, Non-RN