Provider Demographics
NPI:1750706826
Name:NICHOLS, NICOLE L (PMHNP-BC)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:L
Last Name:NICHOLS
Suffix:
Gender:F
Credentials:PMHNP-BC
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:L
Other - Last Name:LUCZAK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:LIFESTANCE HEALTH
Mailing Address - Street 2:7300 DIXIE HWY.
Mailing Address - City:CLARKSTON
Mailing Address - State:MI
Mailing Address - Zip Code:48346
Mailing Address - Country:US
Mailing Address - Phone:248-922-2300
Mailing Address - Fax:248-922-2304
Practice Address - Street 1:LIFESTANCE HEALTH
Practice Address - Street 2:7300 DIXIE HWY.
Practice Address - City:CLARKSTON
Practice Address - State:MI
Practice Address - Zip Code:48346
Practice Address - Country:US
Practice Address - Phone:248-922-2300
Practice Address - Fax:248-922-2304
Is Sole Proprietor?:Yes
Enumeration Date:2014-02-26
Last Update Date:2023-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704296871163W00000X, 363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163W00000XNursing Service ProvidersRegistered Nurse