Healthcare Provider Details

I. General information

NPI: 1568083426
Provider Name (Legal Business Name): SHALETTA NUCKOLLS PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/02/2020
Last Update Date: 03/07/2024
Certification Date: 03/07/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6777 W MAPLE RD
WEST BLOOMFIELD MI
48322-3013
US

IV. Provider business mailing address

6777 W MAPLE RD
WEST BLOOMFIELD MI
48322-3013
US

V. Phone/Fax

Practice location:
  • Phone: 248-325-1000
  • Fax:
Mailing address:
  • Phone: 313-492-0080
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number5601009964
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: