Provider Demographics
NPI:1730781212
Name:BOUMA, ELIZABETH SAYRE (FNP)
Entity type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:SAYRE
Last Name:BOUMA
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2614 THAYER DR
Mailing Address - Street 2:
Mailing Address - City:SAINT JOSEPH
Mailing Address - State:MI
Mailing Address - Zip Code:49085-2032
Mailing Address - Country:US
Mailing Address - Phone:616-886-5705
Mailing Address - Fax:
Practice Address - Street 1:400 S STATE ST STE 250
Practice Address - Street 2:
Practice Address - City:ZEELAND
Practice Address - State:MI
Practice Address - Zip Code:49464-2092
Practice Address - Country:US
Practice Address - Phone:616-741-2364
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-10
Last Update Date:2020-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704322662363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily