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General NPI Number Information
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NPI Number | 1518744499
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Entity Type | Individual
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Provider Name | MARISA LEIGH NICHOLS PA-C
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Gender | Female
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Dates
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Enumeration Date | 09/13/2023
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Last Update Date | 05/12/2025
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Provider Practice Location Address
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Address Line | 23077 GREENFIELD RD STE 253
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City | SOUTHFIELD
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State | MI
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Zip | 48075-3750
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Country | US
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Telephone | 248-559-5950
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Fax | 248-559-2103
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Provider Business Mailing Address
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Address Line | 9919 BERWYN
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City | REDFORD
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State | MI
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Zip | 48239-2120
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Country | US
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Telephone | 734-386-9425
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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 | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number | 5601012050
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License Number State | MI
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