Basic Information
| Provider Information | |||||||||
| NPI: | 1144242371 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KAISER | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | E | ||||||||
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| Credential: | MSN, NP-C, CWOCN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1717 SHAFFER ST | ||||||||
| Address2: | SUITE 202 | ||||||||
| City: | KALAMAZOO | ||||||||
| State: | MI | ||||||||
| PostalCode: | 490481647 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2695520014 | ||||||||
| FaxNumber: | 2695520014 | ||||||||
| Practice Location | |||||||||
| Address1: | 601 JOHN ST STE W-308 | ||||||||
| Address2: | |||||||||
| City: | KALAMAZOO | ||||||||
| State: | MI | ||||||||
| PostalCode: | 490075357 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2693418827 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/24/2006 | ||||||||
| LastUpdateDate: | 12/13/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/13/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LA2200X | 4704166661 | MI | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health |
ID Information
| ID | Type | State | Issuer | Description | 73227731 | 05 | CO | MEDICAID | 4859242 | 05 | MI | MEDICAID |