Basic Information
| Provider Information | |||||||||
| NPI: | 1649541095 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MIEDEMA | ||||||||
| FirstName: | JENNY | ||||||||
| MiddleName: | MONTGOMERY | ||||||||
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| Credential: | RN, MSN, CPNP, NNPBC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2424 ERWIN RD | ||||||||
| Address2: | SUITE 504, NEONATOLOGY | ||||||||
| City: | DURHAM | ||||||||
| State: | NC | ||||||||
| PostalCode: | 277053824 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9199705721 | ||||||||
| FaxNumber: | 9196816065 | ||||||||
| Practice Location | |||||||||
| Address1: | 5524 HOSPITAL N | ||||||||
| Address2: | BOX 100500 MEDICAL CENTER | ||||||||
| City: | DURHAM | ||||||||
| State: | NC | ||||||||
| PostalCode: | 277100001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9199705721 | ||||||||
| FaxNumber: | 9196816065 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/17/2012 | ||||||||
| LastUpdateDate: | 06/23/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 05/20/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LN0005X | 5005122 | NC | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Neonatal, Critical Care |
No ID Information.