Provider Demographics
NPI:1194154476
Name:WIEBER, NICOLE (CPNP)
Entity type:Individual
Prefix:MRS
First Name:NICOLE
Middle Name:
Last Name:WIEBER
Suffix:
Gender:F
Credentials:CPNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1200 E MICHIGAN AVE
Mailing Address - Street 2:STE 145
Mailing Address - City:LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48912-1837
Mailing Address - Country:US
Mailing Address - Phone:517-364-5440
Mailing Address - Fax:517-364-5409
Practice Address - Street 1:1200 E MICHIGAN AVE
Practice Address - Street 2:STE 145
Practice Address - City:LANSING
Practice Address - State:MI
Practice Address - Zip Code:48912-1837
Practice Address - Country:US
Practice Address - Phone:517-364-5440
Practice Address - Fax:517-364-5409
Is Sole Proprietor?:No
Enumeration Date:2013-11-06
Last Update Date:2014-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704242538363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1194154476Medicaid