Provider Demographics
NPI:1164827747
Name:WORTHING, NICHOLE LYNN (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:NICHOLE
Middle Name:LYNN
Last Name:WORTHING
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:32754 SHUE RD
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:MI
Mailing Address - Zip Code:48062-2331
Mailing Address - Country:US
Mailing Address - Phone:248-275-9522
Mailing Address - Fax:
Practice Address - Street 1:40800 WOODWARD AVE
Practice Address - Street 2:
Practice Address - City:BLOOMFIELD HILLS
Practice Address - State:MI
Practice Address - Zip Code:48304-5060
Practice Address - Country:US
Practice Address - Phone:877-433-7767
Practice Address - Fax:877-433-6907
Is Sole Proprietor?:No
Enumeration Date:2014-10-25
Last Update Date:2015-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601005798363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant