Provider Demographics
NPI:1679289326
Name:AMON, NICOLE DANIELLE
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:DANIELLE
Last Name:AMON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:DANIELLE
Other - Last Name:CHURCH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:207 N FRANKLIN ST
Mailing Address - Street 2:
Mailing Address - City:MT PLEASANT
Mailing Address - State:MI
Mailing Address - Zip Code:48858-2303
Mailing Address - Country:US
Mailing Address - Phone:988-824-2374
Mailing Address - Fax:
Practice Address - Street 1:207 N FRANKLIN ST
Practice Address - Street 2:
Practice Address - City:MT PLEASANT
Practice Address - State:MI
Practice Address - Zip Code:48858-2303
Practice Address - Country:US
Practice Address - Phone:989-824-2374
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-26
Last Update Date:2023-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1649360769Medicaid