Healthcare Provider Details

I. General information

NPI: 1770685620
Provider Name (Legal Business Name): NICOLETTE SYLVIA KOWAL FNP-BC, ACNS-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/02/2006
Last Update Date: 04/22/2025
Certification Date: 04/22/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

130 WASHINGTON ST
MARINE CITY MI
48039-1680
US

IV. Provider business mailing address

130 WASHINGTON ST
MARINE CITY MI
48039-1680
US

V. Phone/Fax

Practice location:
  • Phone: 810-765-8750
  • Fax: 810-765-4326
Mailing address:
  • Phone: 810-765-8750
  • Fax: 810-765-4326

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPRN.CNP.0031410
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberNP71014218A
License Number StateIN
# 3
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPRN11024553
License Number StateFL
# 4
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number4704175100
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: