Provider Demographics
NPI:1760024418
Name:LAFONTE, NICOLE ANNA (PA-C)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:ANNA
Last Name:LAFONTE
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1111 LEFFINGWELL AVE NE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49525-6406
Mailing Address - Country:US
Mailing Address - Phone:616-459-7101
Mailing Address - Fax:
Practice Address - Street 1:555 MIDTOWNE ST NE STE 105
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503-5731
Practice Address - Country:US
Practice Address - Phone:616-459-7101
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-15
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601009652363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant