Healthcare Provider Details

I. General information

NPI: 1598492209
Provider Name (Legal Business Name): NICOLE DURHAM RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/03/2022
Last Update Date: 08/03/2022
Certification Date: 07/25/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 CAMPUS DR # 2
HANCOCK MI
49930-1452
US

IV. Provider business mailing address

16260 4TH ST
TRIMOUNTAIN MI
49950
US

V. Phone/Fax

Practice location:
  • Phone: 906-483-1060
  • Fax:
Mailing address:
  • Phone: 989-600-7291
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WA0400X
TaxonomyAddiction (Substance Use Disorder) Registered Nurse
License Number4704315850
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: