Healthcare Provider Details

I. General information

NPI: 1801053285
Provider Name (Legal Business Name): NICOLE L MILLER PAC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: NICOLE L FRETTER PAC

II. Dates (important events)

Enumeration Date: 05/22/2008
Last Update Date: 08/07/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18101 OAKWOOD BLVD
DEARBORN MI
48124-4089
US

IV. Provider business mailing address

38935 ANN ARBOR RD
LIVONIA MI
48150-3397
US

V. Phone/Fax

Practice location:
  • Phone: 313-593-8780
  • Fax: 313-436-2864
Mailing address:
  • Phone: 734-632-0175
  • Fax: 866-250-6385

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number5601005276
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: