Provider Demographics
NPI:1467003921
Name:PACK, NICOLE (CNP)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:PACK
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5700 COOPER FOSTER PARK RD W
Mailing Address - Street 2:
Mailing Address - City:LORAIN
Mailing Address - State:OH
Mailing Address - Zip Code:44053-4152
Mailing Address - Country:US
Mailing Address - Phone:440-204-7400
Mailing Address - Fax:
Practice Address - Street 1:5700 COOPER FOSTER PARK RD W
Practice Address - Street 2:
Practice Address - City:LORAIN
Practice Address - State:OH
Practice Address - Zip Code:44053-4152
Practice Address - Country:US
Practice Address - Phone:440-204-7400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-26
Last Update Date:2023-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH025445363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily