Provider Demographics
NPI:1083016281
Name:WADE, NICOLE (PM)
Entity Type:Individual
Prefix:MISS
First Name:NICOLE
Middle Name:
Last Name:WADE
Suffix:
Gender:F
Credentials:PM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6461 GREENVIEW AVE
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48228-4765
Mailing Address - Country:US
Mailing Address - Phone:313-214-7401
Mailing Address - Fax:
Practice Address - Street 1:7800 W OUTER DR STE 300
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48235-3458
Practice Address - Country:US
Practice Address - Phone:313-340-4442
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-09-18
Last Update Date:2019-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker