Healthcare Provider Details

I. General information

NPI: 1174059810
Provider Name (Legal Business Name): MISS BREANNAH NIKORA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/01/2017
Last Update Date: 12/16/2025
Certification Date: 12/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

124 PEARL ST
YPSILANTI MI
48197-2663
US

IV. Provider business mailing address

124 PEARL ST
YPSILANTI MI
48197-2663
US

V. Phone/Fax

Practice location:
  • Phone: 734-945-6210
  • Fax: 734-822-0119
Mailing address:
  • Phone: 734-945-6210
  • Fax: 734-822-0119

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number6851120997
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: