Provider Demographics
NPI:1356371777
Name:TEMPLEMAN, MICKKI RENAE (CFNP)
Entity type:Individual
Prefix:
First Name:MICKKI
Middle Name:RENAE
Last Name:TEMPLEMAN
Suffix:
Gender:F
Credentials:CFNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:411 W BROADWAY ST
Mailing Address - Street 2:SUITE A
Mailing Address - City:MT PLEASANT
Mailing Address - State:MI
Mailing Address - Zip Code:48858-2446
Mailing Address - Country:US
Mailing Address - Phone:989-772-9523
Mailing Address - Fax:989-772-9052
Practice Address - Street 1:411 W BROADWAY ST
Practice Address - Street 2:SUITE A
Practice Address - City:MOUNT PLEASANT
Practice Address - State:MI
Practice Address - Zip Code:48858-2402
Practice Address - Country:US
Practice Address - Phone:989-772-9523
Practice Address - Fax:989-772-9052
Is Sole Proprietor?:No
Enumeration Date:2006-07-03
Last Update Date:2012-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704184401363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI200000004572OtherPHP COMMERCIAL
MI4520134-11Medicaid
MI1010137OtherMCLAREN HEALTH PLAN
MI5008701250OtherBCBSM
MI5008701250OtherBCBSM
MIN74560009Medicare PIN
MI200000004572OtherPHP COMMERCIAL