Provider Demographics
NPI:1093237166
Name:PERALTA, NICOLE ASHLEY
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:ASHLEY
Last Name:PERALTA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:37595 7 MILE RD STE 230
Mailing Address - Street 2:
Mailing Address - City:LIVONIA
Mailing Address - State:MI
Mailing Address - Zip Code:48152-1003
Mailing Address - Country:US
Mailing Address - Phone:734-853-5694
Mailing Address - Fax:734-430-9388
Practice Address - Street 1:37595 7 MILE RD STE 230
Practice Address - Street 2:
Practice Address - City:LIVONIA
Practice Address - State:MI
Practice Address - Zip Code:48152-1003
Practice Address - Country:US
Practice Address - Phone:734-853-5694
Practice Address - Fax:734-430-9388
Is Sole Proprietor?:Yes
Enumeration Date:2017-07-11
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program