MEDICARE: NICOLE ANTOINETTA THOMAS NP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LF0000X	Family Nurse Practitioner	4704268761	MI

General Provider Information

NPI Number	:	1063076610
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	NICOLE ANTOINETTA THOMAS NP

Provider Business Mailing Address
First Line	:	18451 W 12 MILE RD STE 200
Second Line	:
City	:	LATHRUP VILLAGE
State	:	MI
Zip	:	48076-2635
Country	:	US
Telephone Number	:	248-827-7612
Fax Number	:

Provider Business Practice Location Address
First Line	:	18451 W 12 MILE RD STE 200
Second Line	:
City	:	LATHRUP VILLAGE
State	:	MI
Zip	:	48076-2635
Country	:	US
Telephone Number	:	248-827-7612
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/30/2019
Last Update Date	:	04/30/2019

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