Provider Demographics
NPI:1114738747
Name:WANEK, NICOLE MARIE (RN, DNP, AGA-CNP BC)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:MARIE
Last Name:WANEK
Suffix:
Gender:
Credentials:RN, DNP, AGA-CNP BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:61815 NORTH AVE
Mailing Address - Street 2:
Mailing Address - City:RAY
Mailing Address - State:MI
Mailing Address - Zip Code:48096-3324
Mailing Address - Country:US
Mailing Address - Phone:443-433-8425
Mailing Address - Fax:
Practice Address - Street 1:4100 JOHN R ST
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48201-2013
Practice Address - Country:US
Practice Address - Phone:313-576-9213
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-01-14
Last Update Date:2025-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704293074207RH0003X, 363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
No207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology