| Provider / Organization | NPI | Date Certified |
|---|---|---|
| SHALETTA NUCKOLLS | 1568083426 | 2020-05-02 |
Shaletta Mougoue [F] graduated in 2020 and primarily specializes in Physician Assistant.
Shaletta Nuckolls is registered with the National Plan and Provider Enumeration System and has been issued an National Provider Identifier (NPI) of 1568083426. Registration indicates Shaletta Nuckolls is a provider of access to adult/geriatric primary care providers services with a specialization in Physician Assistants & Advanced Practice Nursing Providers, Physician Assistant Access to Pediatric Primary Care Providers (Physician Assistants & Advanced Practice Nursing Providers, Physician Assistant) (Physician Assistant, ) (Physician Assistants & Advanced Practice Nursing Providers, Physician Assistant) (All Other Specialties & Provider Types, ) (Physician Assistant, Physician Assistants & Advanced Practice Nursing Providers)
| PECOS ID | 4880018092 |
| Registration | PART-B:Y DME:Y HHA:Y PMD:Y |
| Entity Type | Individual |
| Provider Name | Shaletta Nuckolls PA-C |
| Practice Office Address | 6777 W MAPLE RD WEST BLOOMFIELD, MI US |
| Practice Office Telephone | 2483251000 |
| Mailing Address | 6777 W MAPLE RD WEST BLOOMFIELD, MI 483223013 US |
| Business Telephone | 3134920080 |
| Address | City / State | Phone / Fax |
|---|---|---|
| 6777 W Maple Rd | West Bloomfield, MI 483223013 | 2483251000 |
| Direct Messaging Address [] | [email protected] | Direct |
| Direct Messaging Address [] | [email protected] | Direct |
| Direct Messaging Address [] | [email protected] | |
| Direct Messaging Address [] | [email protected] | Direct |
| Code | Practice | License No State |
|---|---|---|
| 363A00000X PRIMARY | Access to Adult/Geriatric Primary Care Providers Physician Assistants & Advanced Practice Nursing Providers Physician AssistantAccess to Pediatric Primary Care Providers Physician Assistants & Advanced Practice Nursing Providers Physician Assistant Physician Assistant Physician Assistants & Advanced Practice Nursing Providers Physician Assistant All Other Specialties & Provider Types Physician Assistant Physician Assistants & Advanced Practice Nursing Providers | 5601009964
MI |