Basic Information
| Provider Information | |||||||||
| NPI: | 1417196395 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | NIEVIEROWSKI | ||||||||
| FirstName: | SHAWNA | ||||||||
| MiddleName: | IRENE | ||||||||
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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: | 9893629411 | ||||||||
| FaxNumber: | 9893629925 | ||||||||
| Practice Location | |||||||||
| Address1: | 1015 S WASHINGTON AVE STE E | ||||||||
| Address2: | |||||||||
| City: | SAGINAW | ||||||||
| State: | MI | ||||||||
| PostalCode: | 48601 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9899077636 | ||||||||
| FaxNumber: | 9899077584 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/17/2009 | ||||||||
| 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 | 363L00000X | 4704230670 | MI | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363LF0000X | 4704230670 | MI | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 1417196395 | 05 | MI | MEDICAID |