Healthcare Provider Details

I. General information

NPI: 1124749429
Provider Name (Legal Business Name): NEDRAE NICHELLE WILSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/06/2022
Last Update Date: 09/06/2022
Certification Date: 09/06/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12501 HAMILTON AVE
HIGHLAND PARK MI
48203-3243
US

IV. Provider business mailing address

12501 HAMILTON AVE
HIGHLAND PARK MI
48203-3243
US

V. Phone/Fax

Practice location:
  • Phone: 313-865-1580
  • Fax:
Mailing address:
  • Phone: 313-865-1580
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WA0400X
TaxonomyAddiction (Substance Use Disorder) Registered Nurse
License Number4704241724
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: