Provider Demographics
NPI:1104497072
Name:CLEMENTS, NICOLLE (MBBCH)
Entity type:Individual
Prefix:DR
First Name:NICOLLE
Middle Name:
Last Name:CLEMENTS
Suffix:
Gender:F
Credentials:MBBCH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1202 W OAK ST STE 200
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:48838-2155
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1202 W OAK ST STE 200
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:MI
Practice Address - Zip Code:48838-2155
Practice Address - Country:US
Practice Address - Phone:616-754-4685
Practice Address - Fax:616-754-9883
Is Sole Proprietor?:No
Enumeration Date:2021-07-01
Last Update Date:2022-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MI4351047979207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program