Provider Demographics
NPI:1508877861
Name:GAGNON, NANCY ANN (APRN,BC)
Entity Type:Individual
Prefix:
First Name:NANCY
Middle Name:ANN
Last Name:GAGNON
Suffix:
Gender:F
Credentials:APRN,BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:455 BARCLAY CIR
Mailing Address - Street 2:SUITE B
Mailing Address - City:ROCHESTER HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48307-4774
Mailing Address - Country:US
Mailing Address - Phone:248-246-1127
Mailing Address - Fax:248-246-0704
Practice Address - Street 1:455 BARCLAY CIR
Practice Address - Street 2:SUITE B
Practice Address - City:ROCHESTER HILLS
Practice Address - State:MI
Practice Address - Zip Code:48307-4774
Practice Address - Country:US
Practice Address - Phone:248-246-1127
Practice Address - Fax:248-246-0704
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-11
Last Update Date:2016-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704120731363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIP59538Medicare UPIN
MI0N50500Medicare ID - Type Unspecified