Provider Demographics
NPI:1063747343
Name:BROWN, KATIE
Entity type:Individual
Prefix:
First Name:KATIE
Middle Name:
Last Name:BROWN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KATIE
Other - Middle Name:
Other - Last Name:NIERENGARTEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1711 S STEPHENSON AVE
Mailing Address - Street 2:STE 300
Mailing Address - City:IRON MOUNTAIN
Mailing Address - State:MI
Mailing Address - Zip Code:49801-3650
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:200 JEFFERSON AVE SE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503-4502
Practice Address - Country:US
Practice Address - Phone:616-685-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-10-05
Last Update Date:2016-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601005617363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant