Provider Demographics
NPI:1669568341
Name:MANDZIARA, MARY A (NP)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:A
Last Name:MANDZIARA
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:A
Other - Last Name:MARCHESE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:19229 MACK AVE
Mailing Address - Street 2:SUITE 23
Mailing Address - City:GROSSE POINTE WOODS
Mailing Address - State:MI
Mailing Address - Zip Code:48236-2858
Mailing Address - Country:US
Mailing Address - Phone:313-647-3245
Mailing Address - Fax:313-647-3244
Practice Address - Street 1:19229 MACK AVE
Practice Address - Street 2:SUITE 34
Practice Address - City:GROSSE POINTE WOODS
Practice Address - State:MI
Practice Address - Zip Code:48236-2858
Practice Address - Country:US
Practice Address - Phone:313-647-3245
Practice Address - Fax:313-647-3244
Is Sole Proprietor?:No
Enumeration Date:2006-10-04
Last Update Date:2014-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704131950363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA4327582Medicaid
MI0866737OtherBCBSM PIN
MI4704131950OtherMICHIGAN LICENSE
MI4704131950OtherMICHIGAN LICENSE