Provider Demographics
NPI:1245011881
Name:NIEDERER, MADISON
Entity type:Individual
Prefix:
First Name:MADISON
Middle Name:
Last Name:NIEDERER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MADISON
Other - Middle Name:
Other - Last Name:MEEKHOFF
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:748 E 132ND ST
Mailing Address - Street 2:
Mailing Address - City:GRANT
Mailing Address - State:MI
Mailing Address - Zip Code:49327-9672
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6425 HARVEY ST
Practice Address - Street 2:
Practice Address - City:NORTON SHORES
Practice Address - State:MI
Practice Address - Zip Code:49444-9739
Practice Address - Country:US
Practice Address - Phone:231-737-3469
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-10-10
Last Update Date:2023-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704334252363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health