Provider Demographics
NPI:1407237548
Name:WIERSMA, ELISE MARIE (AGACNP-BC)
Entity Type:Individual
Prefix:
First Name:ELISE
Middle Name:MARIE
Last Name:WIERSMA
Suffix:
Gender:F
Credentials:AGACNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1560 E MAPLE RD
Mailing Address - Street 2:SUITE 400
Mailing Address - City:TROY
Mailing Address - State:MI
Mailing Address - Zip Code:48083-1138
Mailing Address - Country:US
Mailing Address - Phone:313-966-9777
Mailing Address - Fax:313-966-9767
Practice Address - Street 1:6001 W OUTER DR
Practice Address - Street 2:SUITE 445
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48235-2614
Practice Address - Country:US
Practice Address - Phone:313-966-9777
Practice Address - Fax:313-966-9767
Is Sole Proprietor?:No
Enumeration Date:2015-06-15
Last Update Date:2022-10-26
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MI4704295406363LA2200X, 363LG0600X, 363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology