Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 363L00000X | Nurse Practitioner | 4704199786 | MI |
NPI | 1003969973 |
---|---|
Provider Name | Kathleen Mary Fisher |
First Address | Burton, MI 48519-1455 |
Second Address | Lapeer, MI 48446-3089 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 22/01/2007 |
Last Update Date | 09/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
4706029 | (05) | MI |
5008705180 | BCBSM INDIVIDUAL PIN (01) | MI |