Provider Demographics
NPI:1134558984
Name:NIENABER, JEANETTE L (PA)
Entity type:Individual
Prefix:
First Name:JEANETTE
Middle Name:L
Last Name:NIENABER
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2895
Mailing Address - Street 2:
Mailing Address - City:SEWARD
Mailing Address - State:AK
Mailing Address - Zip Code:99664-2895
Mailing Address - Country:US
Mailing Address - Phone:907-224-2273
Mailing Address - Fax:907-224-8501
Practice Address - Street 1:417 FIRST AVENUE
Practice Address - Street 2:
Practice Address - City:SEWARD
Practice Address - State:AK
Practice Address - Zip Code:99664
Practice Address - Country:US
Practice Address - Phone:907-224-2273
Practice Address - Fax:907-224-8501
Is Sole Proprietor?:No
Enumeration Date:2013-11-02
Last Update Date:2020-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN11495363A00000X
MNIN PROCESS363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK1634651Medicaid