Provider Demographics
NPI:1265986459
Name:LEROY, NICOLE ANN
Entity type:Individual
Prefix:MRS
First Name:NICOLE
Middle Name:ANN
Last Name:LEROY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:984 SPRINGFIELD CT
Mailing Address - Street 2:
Mailing Address - City:NORTHVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:48167-1030
Mailing Address - Country:US
Mailing Address - Phone:248-821-9388
Mailing Address - Fax:
Practice Address - Street 1:984 SPRINGFIELD CT
Practice Address - Street 2:
Practice Address - City:NORTHVILLE
Practice Address - State:MI
Practice Address - Zip Code:48167-1030
Practice Address - Country:US
Practice Address - Phone:248-821-9388
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-05
Last Update Date:2016-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI727212133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered