Healthcare Provider Details

I. General information

NPI: 1932787009
Provider Name (Legal Business Name): NORTHERN HEALTHCARE PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/31/2021
Last Update Date: 01/20/2022
Certification Date: 01/20/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2057 S M 66
EAST JORDAN MI
49727-9169
US

IV. Provider business mailing address

2057 S M 66
EAST JORDAN MI
49727-9169
US

V. Phone/Fax

Practice location:
  • Phone: 231-649-7109
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name: KIMBERLY NICHOLLS
Title or Position: OWNER
Credential: PA
Phone: 231-649-7109