Provider Demographics
NPI:1861153074
Name:KRIKKE, BRANDY JO (LPN)
Entity type:Individual
Prefix:
First Name:BRANDY
Middle Name:JO
Last Name:KRIKKE
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9570 12 MILE RD
Mailing Address - Street 2:
Mailing Address - City:BIG RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49307-9603
Mailing Address - Country:US
Mailing Address - Phone:231-660-3964
Mailing Address - Fax:
Practice Address - Street 1:9570 12 MILE RD
Practice Address - Street 2:
Practice Address - City:BIG RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49307-9603
Practice Address - Country:US
Practice Address - Phone:231-660-3964
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-10
Last Update Date:2022-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIAF370407894253J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253J00000XAgenciesFoster Care Agency
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0724012120051983Medicaid