Healthcare Provider Details

I. General information

NPI: 1992634851
Provider Name (Legal Business Name): NICHOLAS ALAN MOCKERIDGE RN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/18/2026
Last Update Date: 05/18/2026
Certification Date: 05/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1689 WITHERBEE DR
TROY MI
48084-2685
US

IV. Provider business mailing address

1689 WITHERBEE DR
TROY MI
48084-2685
US

V. Phone/Fax

Practice location:
  • Phone: 734-276-8030
  • Fax:
Mailing address:
  • Phone: 734-276-8030
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number4704285766
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: