Provider Demographics
NPI:1114162393
Name:PALMER, MITZI IV
Entity Type:Individual
Prefix:MRS
First Name:MITZI
Middle Name:
Last Name:PALMER
Suffix:IV
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 1:850 DUELL RD
Mailing Address - Street 2:
Mailing Address - City:TRAVERSE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49686-4801
Mailing Address - Country:US
Mailing Address - Phone:231-932-8933
Mailing Address - Fax:
Practice Address - Street 1:850 DUELL RD
Practice Address - Street 2:
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49686-4801
Practice Address - Country:US
Practice Address - Phone:231-932-8933
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-12-02
Last Update Date:2008-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI230388821298376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIPROVIDER ID #4036OtherCMH/ NORTHERN HEALTHCARE MGT