Provider Demographics
NPI:1760121008
Name:MANDZIARA, KARLIE ANN
Entity Type:Individual
Prefix:
First Name:KARLIE
Middle Name:ANN
Last Name:MANDZIARA
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 1:8790 FLAT CREEK DR UNIT D
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:MI
Mailing Address - Zip Code:49341-8948
Mailing Address - Country:US
Mailing Address - Phone:517-285-2764
Mailing Address - Fax:
Practice Address - Street 1:1140 E MICHIGAN AVE STE 400
Practice Address - Street 2:
Practice Address - City:LANSING
Practice Address - State:MI
Practice Address - Zip Code:48912-1806
Practice Address - Country:US
Practice Address - Phone:517-285-2764
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-03
Last Update Date:2023-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601011186363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant