Healthcare Provider Details

I. General information

NPI: 1366165102
Provider Name (Legal Business Name): NICOLE KANOMATA FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/26/2022
Last Update Date: 01/15/2025
Certification Date: 01/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1465 E PARKDALE AVE
MANISTEE MI
49660-9709
US

IV. Provider business mailing address

1105 SIXTH ST
TRAVERSE CITY MI
49684-2386
US

V. Phone/Fax

Practice location:
  • Phone: 231-876-6421
  • Fax: 231-876-6430
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberF10220404
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: