Healthcare Provider Details

I. General information

NPI: 1467113399
Provider Name (Legal Business Name): LAUREN ASHLEY NICKERSON NP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/03/2022
Last Update Date: 09/05/2024
Certification Date: 09/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6152 BELLOWS LAKE RD
LAKE ANN MI
49650-9713
US

IV. Provider business mailing address

302 HOBART ST
CADILLAC MI
49601-2379
US

V. Phone/Fax

Practice location:
  • Phone: 313-590-2631
  • Fax:
Mailing address:
  • Phone: 231-876-2644
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number4704275084
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: