Provider Demographics
NPI:1336892710
Name:ROSE, NICOLETTE L
Entity Type:Individual
Prefix:
First Name:NICOLETTE
Middle Name:L
Last Name:ROSE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:NICOLETTE
Other - Middle Name:L
Other - Last Name:CORNETT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1108 LAPEER RD
Mailing Address - Street 2:
Mailing Address - City:FLINT
Mailing Address - State:MI
Mailing Address - Zip Code:48503-2704
Mailing Address - Country:US
Mailing Address - Phone:810-232-7919
Mailing Address - Fax:810-232-7913
Practice Address - Street 1:1108 LAPEER RD
Practice Address - Street 2:
Practice Address - City:FLINT
Practice Address - State:MI
Practice Address - Zip Code:48503-2704
Practice Address - Country:US
Practice Address - Phone:810-232-7919
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-27
Last Update Date:2022-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)