Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 363LF0000X | Nurse Practitioner - Family Medicine | 4704241860 | MI |
N | 363LP2300X | Nurse Practitioner - Primary Care | 4704241860 | MI |
NPI | 1063562585 |
---|---|
Provider Name | Miss Manjerngie Cecelia Ndebe |
First Address | Portage, MI 49081 |
Second Address | Portage, MI 49024 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 10/01/2007 |
Last Update Date | 06/11/2017 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
12016777 | BCBSM (01) | MI |