Provider Demographics
NPI:1093865032
Name:GILL, NICOLE (NP)
Entity Type:Individual
Prefix:MRS
First Name:NICOLE
Middle Name:
Last Name:GILL
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1498 PACIFIC AVE STE 400
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98402-4208
Mailing Address - Country:US
Mailing Address - Phone:855-768-6363
Mailing Address - Fax:253-682-1714
Practice Address - Street 1:400 HOBART ST
Practice Address - Street 2:
Practice Address - City:CADILLAC
Practice Address - State:MI
Practice Address - Zip Code:49601-2331
Practice Address - Country:US
Practice Address - Phone:231-876-6009
Practice Address - Fax:231-876-6830
Is Sole Proprietor?:No
Enumeration Date:2007-01-11
Last Update Date:2023-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA049613455363LP2300X
GARN124898363LP2300X
MI4704303193363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00000019FMedicaid
GA00000019FMedicaid