Provider Demographics
NPI:1992272496
Name:NICHOLAS, CADELIA (NURSE PRACTITIONER)
Entity type:Individual
Prefix:
First Name:CADELIA
Middle Name:
Last Name:NICHOLAS
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23789 AUSTEN
Mailing Address - Street 2:
Mailing Address - City:FLAT ROCK
Mailing Address - State:MI
Mailing Address - Zip Code:48134-2120
Mailing Address - Country:US
Mailing Address - Phone:313-643-7000
Mailing Address - Fax:
Practice Address - Street 1:250 MCDOUGALL ST
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48207-4291
Practice Address - Country:US
Practice Address - Phone:313-288-7139
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-11-01
Last Update Date:2023-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704287169363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner