Provider Demographics
NPI:1124534938
Name:WIARD, MIRIAM RUTH (FNP)
Entity Type:Individual
Prefix:
First Name:MIRIAM
Middle Name:RUTH
Last Name:WIARD
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:MIRIAM
Other - Middle Name:RUTH
Other - Last Name:MONROE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:601 JOHN STREET
Mailing Address - Street 2:BOX 39
Mailing Address - City:KALAMAZOO
Mailing Address - State:MI
Mailing Address - Zip Code:49007
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5623 GULL RD STE 500
Practice Address - Street 2:
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49048-1098
Practice Address - Country:US
Practice Address - Phone:269-775-8031
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-12-18
Last Update Date:2022-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704299746363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily