Basic Information
| Provider Information | |||||||||
| NPI: | 1083649024 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | NIEMCZYK | ||||||||
| FirstName: | MICHELE | ||||||||
| MiddleName: | L | ||||||||
| NamePrefix: | MISS | ||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1800 COMMUNITY | ||||||||
| Address2: | |||||||||
| City: | CLINTON | ||||||||
| State: | MO | ||||||||
| PostalCode: | 647358804 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6608858131 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1032 CROSSWINDS CT | ||||||||
| Address2: | |||||||||
| City: | WENTZVILLE | ||||||||
| State: | MO | ||||||||
| PostalCode: | 633854836 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8448538937 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/11/2006 | ||||||||
| LastUpdateDate: | 03/25/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 2005017812 | MO | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 207489808 | 05 | MO | MEDICAID |