Provider Demographics
NPI:1972016913
Name:CHAN, NICHOLE (FNP-C)
Entity Type:Individual
Prefix:
First Name:NICHOLE
Middle Name:
Last Name:CHAN
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3200 GREENFIELD RD STE 300
Mailing Address - Street 2:
Mailing Address - City:DEARBORN
Mailing Address - State:MI
Mailing Address - Zip Code:48120-1805
Mailing Address - Country:US
Mailing Address - Phone:855-479-4217
Mailing Address - Fax:888-557-9724
Practice Address - Street 1:3200 GREENFIELD RD STE 300
Practice Address - Street 2:
Practice Address - City:DEARBORN
Practice Address - State:MI
Practice Address - Zip Code:48120-1805
Practice Address - Country:US
Practice Address - Phone:855-479-4217
Practice Address - Fax:888-557-9724
Is Sole Proprietor?:No
Enumeration Date:2017-11-13
Last Update Date:2024-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704254069363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily