Healthcare Provider Details

I. General information

NPI: 1508197534
Provider Name (Legal Business Name): NICOLE MARIE PICKERSGILL CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/14/2010
Last Update Date: 09/30/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2799 W GRAND BLVD
DETROIT MI
48202-2608
US

IV. Provider business mailing address

3037 ROCKWELL BLVD
WINDSOR ONTARIO
N9E 2A6
CA

V. Phone/Fax

Practice location:
  • Phone: 313-874-6256
  • Fax:
Mailing address:
  • Phone: 519-972-0063
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number4704233491
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: