Provider Demographics
NPI:1457664385
Name:ERTL, NICOLE LEIGH (MD)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:LEIGH
Last Name:ERTL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:877 FOREST HILL AVE SE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49546-2380
Mailing Address - Country:US
Mailing Address - Phone:616-949-4465
Mailing Address - Fax:
Practice Address - Street 1:877 FOREST HILL AVE SE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49546-2560
Practice Address - Country:US
Practice Address - Phone:616-391-9377
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-07-20
Last Update Date:2013-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4301096897208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics