Healthcare Provider Details

I. General information

NPI: 1740585033
Provider Name (Legal Business Name): NICOLE RENEE PHILIPPART NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/18/2011
Last Update Date: 05/25/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

33155 ANNAPOLIS ST
WAYNE MI
48184-2405
US

IV. Provider business mailing address

33155 ANNAPOLIS ST
WAYNE MI
48184-2405
US

V. Phone/Fax

Practice location:
  • Phone: 313-586-5011
  • Fax:
Mailing address:
  • Phone: 313-467-4300
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number4704210382
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: