Healthcare Provider Details

I. General information

NPI: 1063562585
Provider Name (Legal Business Name): MANJERNGIE CECELIA NDEBE FNP-C, PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/10/2007
Last Update Date: 11/06/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

451 W. MILHAM AVE
PORTAGE MI
49024
US

IV. Provider business mailing address

P.O. BOX 497
PORTAGE MI
49081
US

V. Phone/Fax

Practice location:
  • Phone: 269-488-9008
  • Fax: 269-488-9001
Mailing address:
  • Phone: 269-488-9008
  • Fax: 269-488-9001

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number4704241860
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number4704241860
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: