1649541095 NPI number — JENNY MONTGOMERY MIEDEMA RN, MSN, CPNP, NNPBC

Table of content: JENNY MONTGOMERY MIEDEMA RN, MSN, CPNP, NNPBC (NPI 1649541095)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1649541095 NPI number — JENNY MONTGOMERY MIEDEMA RN, MSN, CPNP, NNPBC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MIEDEMA
Provider First Name:
JENNY
Provider Middle Name:
MONTGOMERY
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
RN, MSN, CPNP, NNPBC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1649541095
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/23/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2424 ERWIN RD
Provider Second Line Business Mailing Address:
SUITE 504, NEONATOLOGY
Provider Business Mailing Address City Name:
DURHAM
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
27705-3824
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
919-970-5721
Provider Business Mailing Address Fax Number:
919-681-6065

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5524 HOSPITAL N
Provider Second Line Business Practice Location Address:
BOX 100500 MEDICAL CENTER
Provider Business Practice Location Address City Name:
DURHAM
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
27710-0001
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
919-970-5721
Provider Business Practice Location Address Fax Number:
919-681-6065
Provider Enumeration Date:
01/17/2012

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LN0005X , with the licence number:  5005122 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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