Provider Demographics
NPI:1164155800
Name:TEETER, NICOLE (NP)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:TEETER
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 1:2420 OWEN RD STE A
Mailing Address - Street 2:
Mailing Address - City:FENTON
Mailing Address - State:MI
Mailing Address - Zip Code:48430-3417
Mailing Address - Country:US
Mailing Address - Phone:810-496-2500
Mailing Address - Fax:810-629-0415
Practice Address - Street 1:2420 OWEN RD STE A
Practice Address - Street 2:
Practice Address - City:FENTON
Practice Address - State:MI
Practice Address - Zip Code:48430-3417
Practice Address - Country:US
Practice Address - Phone:810-496-2500
Practice Address - Fax:810-629-0415
Is Sole Proprietor?:No
Enumeration Date:2022-07-08
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704341973363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner