Provider Demographics
NPI:1013017516
Name:POMERVILLE, MARY (CNP)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:POMERVILLE
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2100 COMMONWEALTH BLVD
Mailing Address - Street 2:SUITE 202
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48105-1593
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:301 W FRANKLIN ST
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:MI
Practice Address - Zip Code:49236-9744
Practice Address - Country:US
Practice Address - Phone:517-456-7449
Practice Address - Fax:517-456-6059
Is Sole Proprietor?:No
Enumeration Date:2006-09-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704129818363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily