Provider Demographics
NPI:1821316837
Name:FILLMORE, MARY J (ANP)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:J
Last Name:FILLMORE
Suffix:
Gender:F
Credentials:ANP
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:J
Other - Last Name:DORENCZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:721 S WILMOTT ST
Mailing Address - Street 2:
Mailing Address - City:OTSEGO
Mailing Address - State:MI
Mailing Address - Zip Code:49078-1448
Mailing Address - Country:US
Mailing Address - Phone:630-730-3898
Mailing Address - Fax:
Practice Address - Street 1:1521 GULL RD
Practice Address - Street 2:
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49048-1640
Practice Address - Country:US
Practice Address - Phone:269-226-5074
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-05-14
Last Update Date:2023-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209008161363LA2200X
MI4704224949363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health