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General NPI Number Information
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NPI Number | 1114738747
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Entity Type | Individual
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Provider Name | NICOLE MARIE WANEK RN, DNP, AGA-CNP BC
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Gender | Female
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Dates
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Enumeration Date | 01/14/2025
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Last Update Date | 03/03/2025
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Provider Practice Location Address
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Address Line | 4100 JOHN R ST
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City | DETROIT
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State | MI
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Zip | 48201-2013
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Country | US
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Telephone | 313-576-9213
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Fax |
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Provider Business Mailing Address
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Address Line | 61815 NORTH AVE
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City | RAY
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State | MI
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Zip | 48096-3324
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Country | US
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Telephone | 443-433-8425
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207RH0003X
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Taxonomy Name | Hematology & Oncology Physician
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License Number | 4704293074
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License Number State | MI
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Taxonomy #2
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Taxonomy Code | 363LA2100X
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Taxonomy Name | Acute Care Nurse Practitioner
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License Number | 4704293074
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License Number State | MI
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