Basic Information
| Provider Information | |||||||||
| NPI: | 1104313709 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | NICHOLS | ||||||||
| FirstName: | LEANNE | ||||||||
| MiddleName: | MARIE | ||||||||
| NamePrefix: | MS. | ||||||||
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| Credential: | MA, AT, ATC, PES | ||||||||
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| Mailing Information | |||||||||
| Address1: | 144 MANCHESTER LN APT 3211 | ||||||||
| Address2: | |||||||||
| City: | WATERFORD | ||||||||
| State: | MI | ||||||||
| PostalCode: | 483272357 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8108749122 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 4128 E GRAND RIVER AVE | ||||||||
| Address2: | |||||||||
| City: | HOWELL | ||||||||
| State: | MI | ||||||||
| PostalCode: | 488436538 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5175401060 | ||||||||
| FaxNumber: | 5175401063 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/18/2018 | ||||||||
| LastUpdateDate: | 04/18/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2255A2300X | 2601000838 | MI | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Specialist/Technologist | Athletic Trainer |
No ID Information.