Healthcare Provider Details

I. General information

NPI: 1194689026
Provider Name (Legal Business Name): NICOLE HUMBERT PHARMD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/15/2025
Last Update Date: 12/15/2025
Certification Date: 12/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5301 MCAULEY DR
YPSILANTI MI
48197-1051
US

IV. Provider business mailing address

5301 MCAULEY DR
YPSILANTI MI
48197-1051
US

V. Phone/Fax

Practice location:
  • Phone: 734-712-6649
  • Fax:
Mailing address:
  • Phone: 734-712-6649
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1835P1400X
TaxonomyPain Management Pharmacist
License Number5302041793
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: