Basic Information
| Provider Information | |||||||||
| NPI: | 1639611916 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BOIVIN | ||||||||
| FirstName: | NICOLLE | ||||||||
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| NamePrefix: | MRS. | ||||||||
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| Credential: | CPNP-AC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4201 ST. ANTOINE | ||||||||
| Address2: | UNIVERSITY PEDIATRICIANS UHC 5D MAILBOX# | ||||||||
| City: | DETROIT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 48201 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3139665051 | ||||||||
| FaxNumber: | 3139660665 | ||||||||
| Practice Location | |||||||||
| Address1: | 3950 BEAUBIEN | ||||||||
| Address2: | CHM SPEC CTR. GARDEN LEVEL | ||||||||
| City: | DETROIT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 48201 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3138328871 | ||||||||
| FaxNumber: | 3139667445 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/17/2016 | ||||||||
| LastUpdateDate: | 04/27/2017 | ||||||||
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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 | 363LP0200X | 4704253133 | MI | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Pediatrics |
No ID Information.