Provider Demographics
NPI:1588855951
Name:NIEMEYER, MARY SUZANNE
Entity Type:Individual
Prefix:MRS
First Name:MARY
Middle Name:SUZANNE
Last Name:NIEMEYER
Suffix:
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 1:16187 WETHERBY ST
Mailing Address - Street 2:
Mailing Address - City:BEVERLY HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48025-5558
Mailing Address - Country:US
Mailing Address - Phone:248-343-2368
Mailing Address - Fax:
Practice Address - Street 1:33720 HARPER AVE
Practice Address - Street 2:
Practice Address - City:CLINTON TWP
Practice Address - State:MI
Practice Address - Zip Code:48035
Practice Address - Country:US
Practice Address - Phone:586-294-5210
Practice Address - Fax:586-294-0215
Is Sole Proprietor?:No
Enumeration Date:2007-08-09
Last Update Date:2011-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601005147363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant