Provider Demographics
NPI:1114578796
Name:TIGHE, NICOLE ELIZABETH (PA-C)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:ELIZABETH
Last Name:TIGHE
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:461 FLOYD ST
Mailing Address - Street 2:
Mailing Address - City:COOPERSVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:49404-1133
Mailing Address - Country:US
Mailing Address - Phone:616-915-5556
Mailing Address - Fax:
Practice Address - Street 1:4055 CASCADE RD SE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49546-2149
Practice Address - Country:US
Practice Address - Phone:616-252-4410
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-24
Last Update Date:2019-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601009553363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant