Provider Demographics
NPI:1265517494
Name:PAKIESER, MARYLEE (FNP)
Entity type:Individual
Prefix:
First Name:MARYLEE
Middle Name:
Last Name:PAKIESER
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3785 BAY RD
Mailing Address - Street 2:
Mailing Address - City:SAGINAW
Mailing Address - State:MI
Mailing Address - Zip Code:48603-2433
Mailing Address - Country:US
Mailing Address - Phone:989-791-2455
Mailing Address - Fax:
Practice Address - Street 1:4020 COPPER VW STE 104
Practice Address - Street 2:
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49684-7041
Practice Address - Country:US
Practice Address - Phone:231-421-6921
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-26
Last Update Date:2024-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704106641363LF0000X, 363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI104390272Medicaid
MIMP106641OtherBLUE CROSS
MIP18446Medicare UPIN
MI0N70330003Medicare ID - Type UnspecifiedMEDICARE