Provider Demographics
NPI:1861719304
Name:BLACKMER, MARY (NP)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:BLACKMER
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 963
Mailing Address - Street 2:
Mailing Address - City:CADILLAC
Mailing Address - State:MI
Mailing Address - Zip Code:49601-0963
Mailing Address - Country:US
Mailing Address - Phone:231-779-9700
Mailing Address - Fax:231-775-0027
Practice Address - Street 1:7917 MACKINAW TRL
Practice Address - Street 2:
Practice Address - City:CADILLAC
Practice Address - State:MI
Practice Address - Zip Code:49601-9746
Practice Address - Country:US
Practice Address - Phone:231-779-9700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-04-23
Last Update Date:2010-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704116038363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner