Individual
KIMBERLY BOUSEMA
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Credential
PA
Contact information
Practice address
1103 E GRACE ST, RENSSELAER, IN 47978-3251
(219) 866-0411
(219) 866-1920
Mailing address
PO BOX 781076, DETROIT, MI 48278-1076
(317) 528-4800
(317) 865-1479
Taxonomy
Speciality
Code
Description
License number
State
363A00000X
Physician Assistant
Primary
10004742A
IN
390200000X
Student in an Organized Health Care Education/Training Program
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Other
Enumeration date
06/03/2024
Last updated
03/07/2025
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