Provider Demographics
NPI:1679031660
Name:PICKETT, ANTANITA (NP)
Entity Type:Individual
Prefix:
First Name:ANTANITA
Middle Name:
Last Name:PICKETT
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2215 FULLER RD
Mailing Address - Street 2:
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48105-2303
Mailing Address - Country:US
Mailing Address - Phone:734-845-2874
Mailing Address - Fax:
Practice Address - Street 1:2215 FULLER RD
Practice Address - Street 2:
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48105
Practice Address - Country:US
Practice Address - Phone:734-222-7867
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-08
Last Update Date:2019-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704233822363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care