Provider Demographics
NPI:1891796876
Name:LOVE, NICOLE L (PA)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:L
Last Name:LOVE
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:L
Other - Last Name:BRADFORD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:PO BOX 1847
Mailing Address - Street 2:
Mailing Address - City:MUSKEGON
Mailing Address - State:MI
Mailing Address - Zip Code:49443-1847
Mailing Address - Country:US
Mailing Address - Phone:231-727-5211
Mailing Address - Fax:231-727-4571
Practice Address - Street 1:1212 E SHERMAN BLVD
Practice Address - Street 2:
Practice Address - City:MUSKEGON
Practice Address - State:MI
Practice Address - Zip Code:49444
Practice Address - Country:US
Practice Address - Phone:231-672-3500
Practice Address - Fax:231-672-6199
Is Sole Proprietor?:No
Enumeration Date:2005-08-02
Last Update Date:2018-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601004151363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIQ09743Medicare UPIN