MEDICARE: MISS PRIMA MARDHATILLAH MUZIRMAN NP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LF0000X	Family Nurse Practitioner	4704248754	MI

General Provider Information

NPI Number	:	1437551595
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MISS PRIMA MARDHATILLAH MUZIRMAN NP

Provider Business Mailing Address
First Line	:	6346 BEECHFIELD DR
Second Line	:
City	:	LANSING
State	:	MI
Zip	:	48911-5735
Country	:	US
Telephone Number	:	517-410-1388
Fax Number	:

Provider Business Practice Location Address
First Line	:	1780 E PARNALL RD
Second Line	:
City	:	JACKSON
State	:	MI
Zip	:	49201-7136
Country	:	US
Telephone Number	:	517-780-6004
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/19/2014
Last Update Date	:	09/19/2014

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