Healthcare Provider Details

I. General information

NPI: 1235006248
Provider Name (Legal Business Name): BIANCA NOEL NOLTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/22/2025
Last Update Date: 03/20/2026
Certification Date: 03/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 N WEST AVE
JACKSON MI
49202-2179
US

IV. Provider business mailing address

48245 MANHATTAN CIR
CANTON MI
48188-1498
US

V. Phone/Fax

Practice location:
  • Phone: 800-284-8288
  • Fax:
Mailing address:
  • Phone: 734-756-1133
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number4704318922
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number4704318922NSA2606R
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: