Provider Demographics
NPI:1063771087
Name:PHILLIPS, NICOLE ALEXIS (MD (6/12))
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:ALEXIS
Last Name:PHILLIPS
Suffix:
Gender:F
Credentials:MD (6/12)
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:75 FRANCIS ST
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02115-6110
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3901 STONEGATE PARK STE 300
Practice Address - Street 2:
Practice Address - City:SAINT JOSEPH
Practice Address - State:MI
Practice Address - Zip Code:49085-9136
Practice Address - Country:US
Practice Address - Phone:269-556-6000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-05-10
Last Update Date:2020-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301502412208200000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program