Healthcare Provider Details

I. General information

NPI: 1912819608
Provider Name (Legal Business Name): NICHOLE L OSGOOD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/18/2026
Last Update Date: 09/18/2026
Certification Date: 09/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1408 FOREST DR
PORTAGE MI
49002-6320
US

IV. Provider business mailing address

1408 FOREST DR
PORTAGE MI
49002-6320
US

V. Phone/Fax

Practice location:
  • Phone: 269-312-6749
  • Fax:
Mailing address:
  • Phone: 269-312-6749
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: