Provider Demographics
NPI:1457704983
Name:KNOTTS, JEANNIE MARIE (NP)
Entity Type:Individual
Prefix:
First Name:JEANNIE
Middle Name:MARIE
Last Name:KNOTTS
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:JEANNIE
Other - Middle Name:M
Other - Last Name:MUKA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP-C
Mailing Address - Street 1:21333 HAGGERTY RD
Mailing Address - Street 2:SUITE 150
Mailing Address - City:NOVI
Mailing Address - State:MI
Mailing Address - Zip Code:48375-5514
Mailing Address - Country:US
Mailing Address - Phone:800-979-9595
Mailing Address - Fax:248-662-9845
Practice Address - Street 1:2825 BLOOMFIELD RD.
Practice Address - Street 2:
Practice Address - City:CAPE GIRARDEAU
Practice Address - State:MO
Practice Address - Zip Code:63703-6398
Practice Address - Country:US
Practice Address - Phone:800-979-9595
Practice Address - Fax:248-662-9845
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-20
Last Update Date:2024-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2016019536363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily