Healthcare Provider Details

I. General information

NPI: 1588855951
Provider Name (Legal Business Name): MRS. MARY SUZANNE NIEMEYER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/09/2007
Last Update Date: 07/01/2026
Certification Date: 07/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

836 PRUDENTIAL DR
JACKSONVILLE FL
32207-8334
US

IV. Provider business mailing address

1343 GROSVENOR SQUARE DR
JACKSONVILLE FL
32207-1903
US

V. Phone/Fax

Practice location:
  • Phone: 904-510-5054
  • Fax:
Mailing address:
  • Phone: 904-510-5054
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number5601005147
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: