Provider Demographics
NPI:1477530475
Name:NIEMEYER, MARY J (FNP)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:J
Last Name:NIEMEYER
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3828 KENTUCKY LANE
Mailing Address - Street 2:
Mailing Address - City:HUDSONVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:49426-0000
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3828 KENTUCKY LN
Practice Address - Street 2:
Practice Address - City:HUDSONVILLE
Practice Address - State:MI
Practice Address - Zip Code:49426-8107
Practice Address - Country:US
Practice Address - Phone:616-340-4633
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-30
Last Update Date:2014-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704190536363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIP00321466OtherRAILROAD MEDICARE
MN190536OtherBLUE CROSS BLUE SHIELD
MI4831608Medicaid
MI4831608Medicaid
MID16091078Medicare Oscar/Certification