Provider Demographics
NPI:1154647790
Name:MIKULSKI, NICOLE RENEE (DPT)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:RENEE
Last Name:MIKULSKI
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:RENEE
Other - Last Name:GIANOTTI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DPT
Mailing Address - Street 1:1080 KIRTS BLVD STE 300
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:MI
Mailing Address - Zip Code:48084-4884
Mailing Address - Country:US
Mailing Address - Phone:248-353-1234
Mailing Address - Fax:586-275-0735
Practice Address - Street 1:14901 23 MILE RD STE C
Practice Address - Street 2:
Practice Address - City:SHELBY TWP
Practice Address - State:MI
Practice Address - Zip Code:48315-3009
Practice Address - Country:US
Practice Address - Phone:248-353-1234
Practice Address - Fax:586-566-5816
Is Sole Proprietor?:No
Enumeration Date:2010-04-07
Last Update Date:2021-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501015067225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI250454OtherMERIDIAN
MIOH71408OtherBCBSM
MI650E031940OtherBCBSM