Provider Demographics
NPI:1639124670
Name:MASON, NANCY MARIE (NP)
Entity Type:Individual
Prefix:MS
First Name:NANCY
Middle Name:MARIE
Last Name:MASON
Suffix:
Gender:F
Credentials:NP
Other - Prefix:MS
Other - First Name:NANCY
Other - Middle Name:MARIE
Other - Last Name:KROL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:43800 GARFIELD RD
Mailing Address - Street 2:SUITE 201
Mailing Address - City:CLINTON TOWNSHIP
Mailing Address - State:MI
Mailing Address - Zip Code:48038-1136
Mailing Address - Country:US
Mailing Address - Phone:586-228-4652
Mailing Address - Fax:586-228-4520
Practice Address - Street 1:2200 WOODWARD HTS
Practice Address - Street 2:
Practice Address - City:FERNDALE
Practice Address - State:MI
Practice Address - Zip Code:48220-3007
Practice Address - Country:US
Practice Address - Phone:248-543-4138
Practice Address - Fax:248-543-4252
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704149798363LP0200X, 363LS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Not Answered363LS0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4830520Medicaid
MI0865710OtherBCBS PIN
MI4704149798OtherLICENSE