Provider Demographics
NPI:1194011320
Name:KNISLEY, NICOLE ROSE (PA-C)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:ROSE
Last Name:KNISLEY
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 1:1600 S CANTON CENTER RD
Mailing Address - Street 2:#140
Mailing Address - City:CANTON
Mailing Address - State:MI
Mailing Address - Zip Code:48188-1992
Mailing Address - Country:US
Mailing Address - Phone:734-398-7561
Mailing Address - Fax:734-398-7566
Practice Address - Street 1:1600 S CANTON CENTER RD
Practice Address - Street 2:#140
Practice Address - City:CANTON
Practice Address - State:MI
Practice Address - Zip Code:48188-1992
Practice Address - Country:US
Practice Address - Phone:734-398-7561
Practice Address - Fax:734-398-7566
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-27
Last Update Date:2014-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601006025363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical