Provider Demographics
NPI:1346018314
Name:MOLAND, NIKELA MATHEW
Entity Type:Individual
Prefix:
First Name:NIKELA
Middle Name:MATHEW
Last Name:MOLAND
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:NIKELA
Other - Middle Name:
Other - Last Name:POLLARD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1410 SHARE AVE APT 201
Mailing Address - Street 2:
Mailing Address - City:YPSILANTI
Mailing Address - State:MI
Mailing Address - Zip Code:48198-6559
Mailing Address - Country:US
Mailing Address - Phone:313-334-0904
Mailing Address - Fax:
Practice Address - Street 1:9111 GRANDVILLE AVE
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48228-1712
Practice Address - Country:US
Practice Address - Phone:313-334-0904
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-12-19
Last Update Date:2023-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI7501011971225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist