Healthcare Provider Details

I. General information

NPI: 1295654796
Provider Name (Legal Business Name): NICOLE LYNN GRACE MS, EDS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: NICOLE LYNN WINTERS

II. Dates (important events)

Enumeration Date: 07/10/2026
Last Update Date: 07/10/2026
Certification Date: 07/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11051 N CUT RD
ROSCOMMON MI
48653-9332
US

IV. Provider business mailing address

11051 N CUT RD
ROSCOMMON MI
48653-9332
US

V. Phone/Fax

Practice location:
  • Phone: 989-390-9609
  • Fax:
Mailing address:
  • Phone: 989-390-9609
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number7101002921
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: