Healthcare Provider Details

I. General information

NPI: 1881193845
Provider Name (Legal Business Name): MS. ELIZABETH NUCKOLLS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: ELIZABETH POWERS

II. Dates (important events)

Enumeration Date: 02/06/2018
Last Update Date: 02/06/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8542 HOLLY RD
GRAND BLANC MI
48439
US

IV. Provider business mailing address

8542 HOLLY RD
GRAND BLANC MI
48439
US

V. Phone/Fax

Practice location:
  • Phone: 810-603-7887
  • Fax: 810-720-1306
Mailing address:
  • Phone: 810-603-7887
  • Fax: 810-720-1306

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number2902014045
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: