Provider Demographics
NPI:1720785298
Name:NIEMAN, MARIAH RENAE (FNP)
Entity Type:Individual
Prefix:
First Name:MARIAH
Middle Name:RENAE
Last Name:NIEMAN
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 1:49725 COUNTY ROAD 83
Mailing Address - Street 2:
Mailing Address - City:STAPLES
Mailing Address - State:MN
Mailing Address - Zip Code:56479
Mailing Address - Country:US
Mailing Address - Phone:218-894-1515
Mailing Address - Fax:
Practice Address - Street 1:49725 COUNTY ROAD 83
Practice Address - Street 2:
Practice Address - City:STAPLES
Practice Address - State:MN
Practice Address - Zip Code:56479
Practice Address - Country:US
Practice Address - Phone:218-894-1515
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-02-14
Last Update Date:2024-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN9876363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily