Provider Demographics
NPI:1063562585
Name:NDEBE, MANJERNGIE CECELIA (FNP-C, PHD)
Entity type:Individual
Prefix:MISS
First Name:MANJERNGIE
Middle Name:CECELIA
Last Name:NDEBE
Suffix:
Gender:F
Credentials:FNP-C, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P.O. BOX 497
Mailing Address - Street 2:
Mailing Address - City:PORTAGE
Mailing Address - State:MI
Mailing Address - Zip Code:49081
Mailing Address - Country:US
Mailing Address - Phone:269-488-9008
Mailing Address - Fax:269-488-9001
Practice Address - Street 1:451 W. MILHAM AVE
Practice Address - Street 2:
Practice Address - City:PORTAGE
Practice Address - State:MI
Practice Address - Zip Code:49024
Practice Address - Country:US
Practice Address - Phone:269-488-9008
Practice Address - Fax:269-488-9001
Is Sole Proprietor?:No
Enumeration Date:2007-01-10
Last Update Date:2017-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704241860363LP2300X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI12016777OtherBCBSM