Provider Demographics
NPI:1831765536
Name:MAZHAR, NICHOLE ELIZABETH (NP)
Entity type:Individual
Prefix:
First Name:NICHOLE
Middle Name:ELIZABETH
Last Name:MAZHAR
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26901 BEAUMONT BLVD STE 3D
Mailing Address - Street 2:
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48033-3849
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:36555 26 MILE RD STE 1100
Practice Address - Street 2:
Practice Address - City:LENOX
Practice Address - State:MI
Practice Address - Zip Code:48048-3186
Practice Address - Country:US
Practice Address - Phone:947-523-4010
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-02
Last Update Date:2023-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN2339148363L00000X
MI4704321238363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner