Provider Demographics
NPI:1609402353
Name:NIEMCZURA, MARY
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:NIEMCZURA
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 1:9900 BERN ROAD EAST
Mailing Address - Street 2:MAIL ROUTE MN 008-B213
Mailing Address - City:MINNETONKA
Mailing Address - State:MN
Mailing Address - Zip Code:55343
Mailing Address - Country:US
Mailing Address - Phone:999-999-9999
Mailing Address - Fax:
Practice Address - Street 1:3803 N ELM ST
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27455-2593
Practice Address - Country:US
Practice Address - Phone:336-999-9999
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-13
Last Update Date:2020-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5013114363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner