Provider Demographics
NPI:1710466024
Name:CAMERON, NICOLE SUSANNE (NP)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:SUSANNE
Last Name:CAMERON
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 1:400 HOBART ST
Mailing Address - Street 2:
Mailing Address - City:CADILLAC
Mailing Address - State:MI
Mailing Address - Zip Code:49601-2331
Mailing Address - Country:US
Mailing Address - Phone:231-876-7807
Mailing Address - Fax:
Practice Address - Street 1:1250 E MICHIGAN AVE
Practice Address - Street 2:
Practice Address - City:GRAYLING
Practice Address - State:MI
Practice Address - Zip Code:49738
Practice Address - Country:US
Practice Address - Phone:989-348-0550
Practice Address - Fax:989-348-0473
Is Sole Proprietor?:No
Enumeration Date:2018-08-08
Last Update Date:2020-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704296224363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner