=====================================================
General NPI Number Information
=====================================================
NPI Number | 1164155800
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | NICOLE TEETER NP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/08/2022
-----------------------------------------------------
Last Update Date | 11/27/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2420 OWEN RD STE A
-----------------------------------------------------
City | FENTON
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48430-3417
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 810-496-2500
-----------------------------------------------------
Fax | 810-629-0415
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2420 OWEN RD STE A
-----------------------------------------------------
City | FENTON
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48430-3417
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 810-496-2500
-----------------------------------------------------
Fax | 810-629-0415
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363L00000X
-----------------------------------------------------
Taxonomy Name | Nurse Practitioner
-----------------------------------------------------
License Number | 4704341973
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------