Provider Demographics
NPI:1992465728
Name:REA, NICOLE
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:REA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:29500 SOUTHFIELD RD STE 100
Mailing Address - Street 2:
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48076-2036
Mailing Address - Country:US
Mailing Address - Phone:248-880-7780
Mailing Address - Fax:
Practice Address - Street 1:29500 SOUTHFIELD RD STE 100
Practice Address - Street 2:
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48076-2036
Practice Address - Country:US
Practice Address - Phone:248-880-7780
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-12-21
Last Update Date:2024-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704279021363LP0808X, 163WP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health