Provider Demographics
NPI:1558241109
Name:BRUNETTE, LISA
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:BRUNETTE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10891 2ND AVE NW
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49534-5892
Mailing Address - Country:US
Mailing Address - Phone:616-570-4647
Mailing Address - Fax:
Practice Address - Street 1:6534 LAKE MICHIGAN DR
Practice Address - Street 2:
Practice Address - City:ALLENDALE
Practice Address - State:MI
Practice Address - Zip Code:49401-9228
Practice Address - Country:US
Practice Address - Phone:616-895-5499
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-09-04
Last Update Date:2025-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2301401656111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor