Provider Demographics
NPI:1801592647
Name:NORDSTROM, KYLE JAMES (DNP, AGACNP-BC)
Entity type:Individual
Prefix:
First Name:KYLE
Middle Name:JAMES
Last Name:NORDSTROM
Suffix:
Gender:M
Credentials:DNP, AGACNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2250 ROLLINS ST
Mailing Address - Street 2:
Mailing Address - City:GRAND BLANC
Mailing Address - State:MI
Mailing Address - Zip Code:48439-4338
Mailing Address - Country:US
Mailing Address - Phone:810-397-3950
Mailing Address - Fax:
Practice Address - Street 1:4000 WELLNESS DR
Practice Address - Street 2:
Practice Address - City:MIDLAND
Practice Address - State:MI
Practice Address - Zip Code:48670-2000
Practice Address - Country:US
Practice Address - Phone:989-837-9090
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-02-03
Last Update Date:2023-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704321425NSA2302O363LA2100X
MI4704321425363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care