1164827747 NPI number — MRS. NICHOLE LYNN WORTHING PA-C

Table of content: MRS. NICHOLE LYNN WORTHING PA-C (NPI 1164827747)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1164827747 NPI number — MRS. NICHOLE LYNN WORTHING PA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WORTHING
Provider First Name:
NICHOLE
Provider Middle Name:
LYNN
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
PA-C
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1164827747
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/18/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
32754 SHUE RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
RICHMOND
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48062-2331
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
248-275-9522
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
40800 WOODWARD AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BLOOMFIELD HILLS
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48304-5060
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
877-433-7767
Provider Business Practice Location Address Fax Number:
877-433-6907
Provider Enumeration Date:
10/25/2014

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363A00000X , with the licence number:  5601005798 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





Copyright © 2007-2024 www.npivalidator.com