Provider Demographics
NPI:1689271314
Name:CONKLIN, NICOLE (NP)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:CONKLIN
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 1:4221 CHARLAR DR
Mailing Address - Street 2:
Mailing Address - City:HOLT
Mailing Address - State:MI
Mailing Address - Zip Code:48842-6804
Mailing Address - Country:US
Mailing Address - Phone:517-694-7600
Mailing Address - Fax:517-694-7003
Practice Address - Street 1:524 DOYLE RD
Practice Address - Street 2:
Practice Address - City:LAINGSBURG
Practice Address - State:MI
Practice Address - Zip Code:48848-9611
Practice Address - Country:US
Practice Address - Phone:517-294-0681
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-06
Last Update Date:2020-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704253647363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner