Provider Demographics
NPI:1558086819
Name:RUSINOWSKI, NICOLE SCHANTA (A-GNP-C)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:SCHANTA
Last Name:RUSINOWSKI
Suffix:
Gender:F
Credentials:A-GNP-C
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:
Other - Last Name:SCHANTA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1319 S WASHINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:ROYAL OAK
Mailing Address - State:MI
Mailing Address - Zip Code:48067-3200
Mailing Address - Country:US
Mailing Address - Phone:586-524-5968
Mailing Address - Fax:
Practice Address - Street 1:41800 W 11 MILE RD STE 109
Practice Address - Street 2:
Practice Address - City:NOVI
Practice Address - State:MI
Practice Address - Zip Code:48375-1818
Practice Address - Country:US
Practice Address - Phone:586-524-5968
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-10-10
Last Update Date:2024-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704321524363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner