Healthcare Provider Details

I. General information

NPI: 1497715130
Provider Name (Legal Business Name): SUSAN GAYLE WIERS NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/25/2006
Last Update Date: 05/19/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

35050 23 MILE RD SUITE B
NEW BALTIMORE MI
48047-3606
US

IV. Provider business mailing address

43750 GARFIELD RD SUITE 104
CLINTON TWP MI
48038-1135
US

V. Phone/Fax

Practice location:
  • Phone: 586-725-0477
  • Fax: 586-725-8835
Mailing address:
  • Phone: 586-226-6865
  • Fax: 586-226-6880

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number4704135893
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code163WG0000X
TaxonomyGeneral Practice Registered Nurse
License Number4704135893
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: