Healthcare Provider Details

I. General information

NPI: 1629532833
Provider Name (Legal Business Name): MEGAN ASHLEY NICKLAUS CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MEGAN ASHLEY PITTOORS

II. Dates (important events)

Enumeration Date: 01/22/2019
Last Update Date: 12/18/2024
Certification Date: 12/18/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3601 W 13 MILE RD
ROYAL OAK MI
48073-6712
US

IV. Provider business mailing address

20363 BREEZEWAY DR
MACOMB MI
48044-3515
US

V. Phone/Fax

Practice location:
  • Phone: 586-914-6310
  • Fax:
Mailing address:
  • Phone: 586-263-4475
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number4704297002
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: