Provider Demographics
NPI:1972900801
Name:KANNETH, NICOLE (MACP)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:KANNETH
Suffix:
Gender:F
Credentials:MACP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:27827 ONEIL ST
Mailing Address - Street 2:
Mailing Address - City:ROSEVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:48066-3022
Mailing Address - Country:US
Mailing Address - Phone:313-461-5218
Mailing Address - Fax:
Practice Address - Street 1:27827 ONEIL ST
Practice Address - Street 2:
Practice Address - City:ROSEVILLE
Practice Address - State:MI
Practice Address - Zip Code:48066-3022
Practice Address - Country:US
Practice Address - Phone:313-461-5218
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-11-20
Last Update Date:2014-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other