Healthcare Provider Details

I. General information

NPI: 1275495020
Provider Name (Legal Business Name): ANNALIESE ELISABETH BANGERT FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/01/2025
Last Update Date: 12/01/2025
Certification Date: 12/01/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1602 W MICHIGAN AVE
JACKSON MI
49202-4003
US

IV. Provider business mailing address

1602 W MICHIGAN AVE
JACKSON MI
49202-4003
US

V. Phone/Fax

Practice location:
  • Phone: 517-879-1166
  • Fax: 517-879-5122
Mailing address:
  • Phone: 517-879-1166
  • Fax: 517-879-5122

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number4704363750
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: