Provider Demographics
NPI:1407545049
Name:NICEWANDER, MICHELLE RENAE (FNP)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:RENAE
Last Name:NICEWANDER
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:MICHELLE
Other - Middle Name:RENAE
Other - Last Name:DUDONIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:100 MICHIGAN ST NE # MC845
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-2560
Mailing Address - Country:US
Mailing Address - Phone:616-486-6790
Mailing Address - Fax:
Practice Address - Street 1:1 ATKINSON DR
Practice Address - Street 2:
Practice Address - City:LUDINGTON
Practice Address - State:MI
Practice Address - Zip Code:49431-1906
Practice Address - Country:US
Practice Address - Phone:231-845-2301
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-01
Last Update Date:2023-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704322163363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily