Healthcare Provider Details

I. General information

NPI: 1992465728
Provider Name (Legal Business Name): NICOLE REA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/21/2021
Last Update Date: 08/20/2026
Certification Date: 08/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

31560 SCHOOLCRAFT RD
LIVONIA MI
48150-1805
US

IV. Provider business mailing address

31560 SCHOOLCRAFT RD
LIVONIA MI
48150-1805
US

V. Phone/Fax

Practice location:
  • Phone: 248-880-7780
  • Fax: 248-294-1253
Mailing address:
  • Phone:
  • Fax: 248-294-1253

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number4704279021
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: