Provider Demographics
NPI:1538828223
Name:VANMALDEGHEM, NICOLETTE (DNP, RN, AGACNP-BC)
Entity type:Individual
Prefix:
First Name:NICOLETTE
Middle Name:
Last Name:VANMALDEGHEM
Suffix:
Gender:F
Credentials:DNP, RN, AGACNP-BC
Other - Prefix:
Other - First Name:NICOLETTE
Other - Middle Name:
Other - Last Name:VANMALDEGHEM
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DNP, RN, AGACNP-BC
Mailing Address - Street 1:47450 JUNIPER RD
Mailing Address - Street 2:
Mailing Address - City:MACOMB
Mailing Address - State:MI
Mailing Address - Zip Code:48044-2434
Mailing Address - Country:US
Mailing Address - Phone:248-495-9859
Mailing Address - Fax:
Practice Address - Street 1:5280 METROPOLITAN PKWY
Practice Address - Street 2:
Practice Address - City:STERLING HEIGHTS
Practice Address - State:MI
Practice Address - Zip Code:48310-4005
Practice Address - Country:US
Practice Address - Phone:586-722-7519
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-12-10
Last Update Date:2022-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704329215363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner