Healthcare Provider Details

I. General information

NPI: 1205148681
Provider Name (Legal Business Name): NICOLE M CRESALIA M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/13/2010
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 PARNASSUS AVE
SAN FRANCISCO CA
94143-2202
US

IV. Provider business mailing address

3621 S STATE ST 700 KMS PLACE
ANN ARBOR MI
48108
US

V. Phone/Fax

Practice location:
  • Phone: 415-476-1000
  • Fax:
Mailing address:
  • Phone: 734-936-2047
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberA149944
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number4301102334
License Number StateMI
# 3
Primary TaxonomyN
Taxonomy Code2080P0202X
TaxonomyPediatric Cardiology Physician
License Number4301102334
License Number StateMI
# 4
Primary TaxonomyY
Taxonomy Code2080P0202X
TaxonomyPediatric Cardiology Physician
License NumberA149944
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: