Provider Demographics
NPI:1710213889
Name:MUHAMMAD, NICOLE DONYALE (LPN)
Entity Type:Individual
Prefix:MS
First Name:NICOLE
Middle Name:DONYALE
Last Name:MUHAMMAD
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22563 GROVE CT
Mailing Address - Street 2:206
Mailing Address - City:NOVI
Mailing Address - State:MI
Mailing Address - Zip Code:48375-4573
Mailing Address - Country:US
Mailing Address - Phone:313-645-6631
Mailing Address - Fax:
Practice Address - Street 1:22563 GROVE CT
Practice Address - Street 2:206
Practice Address - City:NOVI
Practice Address - State:MI
Practice Address - Zip Code:48375-4573
Practice Address - Country:US
Practice Address - Phone:313-645-6631
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-10-26
Last Update Date:2009-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4703100917164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4703100917Medicaid