Healthcare Provider Details

I. General information

NPI: 1427553635
Provider Name (Legal Business Name): NICOLE MOKANYK LPTA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/28/2018
Last Update Date: 06/16/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15101 FORD RD
DEARBORN MI
48126-4611
US

IV. Provider business mailing address

3200 VASSAR ST
DEARBORN MI
48124-3571
US

V. Phone/Fax

Practice location:
  • Phone: 877-660-1807
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number5502003598
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: