Provider Demographics
NPI:1659382265
Name:REUL, NICOLE L
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:L
Last Name:REUL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10853 STATE RD
Mailing Address - Street 2:
Mailing Address - City:RIVES JUNCTION
Mailing Address - State:MI
Mailing Address - Zip Code:49277-9736
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:300 W WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MI
Practice Address - Zip Code:49201-2180
Practice Address - Country:US
Practice Address - Phone:517-783-4664
Practice Address - Fax:517-783-4698
Is Sole Proprietor?:No
Enumeration Date:2006-08-10
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601003752363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5601003752OtherSTATE LICENSE NUMBER
MIMR1091064OtherDEA NUMBER
MI5601003752OtherSTATE LICENSE NUMBER