Healthcare Provider Details

I. General information

NPI: 1578917381
Provider Name (Legal Business Name): JENNIFER SUE NIMTZ D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/18/2016
Last Update Date: 02/23/2026
Certification Date: 02/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17900 23 MILE RD STE 101
MACOMB MI
48044-1161
US

IV. Provider business mailing address

17900 23 MILE RD STE 101
MACOMB MI
48044-1161
US

V. Phone/Fax

Practice location:
  • Phone: 586-868-9010
  • Fax:
Mailing address:
  • Phone: 586-868-9010
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number5101022645
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: