Basic Information
| Provider Information | |||||||||
| NPI: | 1194979955 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KOLBIAZ | ||||||||
| FirstName: | JENNIFER | ||||||||
| MiddleName: | LEE | ||||||||
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| Credential: | FNP-BC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 779 | ||||||||
| Address2: | |||||||||
| City: | TAWAS CITY | ||||||||
| State: | MI | ||||||||
| PostalCode: | 487640779 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8552989888 | ||||||||
| FaxNumber: | 9894973125 | ||||||||
| Practice Location | |||||||||
| Address1: | 4677 TOWNE CENTRE RD STE 301 | ||||||||
| Address2: | |||||||||
| City: | SAGINAW | ||||||||
| State: | MI | ||||||||
| PostalCode: | 48604 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8552989888 | ||||||||
| FaxNumber: | 9894973128 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/06/2008 | ||||||||
| LastUpdateDate: | 04/06/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/06/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 4704225779 | MI | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 194526 | 01 | MI | GREAT LAKES HEALTH PLAN | OTHER | 500G310570 | 01 | MI | BLUE CROSS BLUE SHIELD OF MICHIGAN | OTHER | 62748 | 01 | MI | MERIDIAN HEALTH PLAN | OTHER | 078 | 01 | MI | CARE SOURCE OF MICHIGAN | OTHER | 381908328 | 01 | MI | HCAP | OTHER | 1194979955 | 01 | MO | MOLINA HEALTH CARE OF MICHIGAN | OTHER | 1194979955 | 05 | MI | MEDICAID |