Provider Demographics
NPI:1083275408
Name:STEVENS, NICHOLAS (MAT, ATC)
Entity Type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:
Last Name:STEVENS
Suffix:
Gender:M
Credentials:MAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:348 HIGH ST
Mailing Address - Street 2:
Mailing Address - City:MARSHALL
Mailing Address - State:MI
Mailing Address - Zip Code:49068-1222
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1 CAMPUS DR
Practice Address - Street 2:
Practice Address - City:ALLENDALE
Practice Address - State:MI
Practice Address - Zip Code:49401-9401
Practice Address - Country:US
Practice Address - Phone:616-331-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-26
Last Update Date:2021-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer