Provider Demographics
NPI:1356534770
Name:GRANGE, NICOLE DAWN (PA-C)
Entity type:Individual
Prefix:MRS
First Name:NICOLE
Middle Name:DAWN
Last Name:GRANGE
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:DAWN
Other - Last Name:JOSEPH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:1181 N MILFORD RD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:MILFORD
Mailing Address - State:MI
Mailing Address - Zip Code:48381-1061
Mailing Address - Country:US
Mailing Address - Phone:248-685-0444
Mailing Address - Fax:248-684-0900
Practice Address - Street 1:1181 N MILFORD RD
Practice Address - Street 2:SUITE 100
Practice Address - City:MILFORD
Practice Address - State:MI
Practice Address - Zip Code:48381-1061
Practice Address - Country:US
Practice Address - Phone:248-685-0444
Practice Address - Fax:248-684-0900
Is Sole Proprietor?:No
Enumeration Date:2007-08-20
Last Update Date:2011-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601005010363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant