Provider Demographics
NPI:1164898722
Name:GAGLIARDI, NICOLE A (NP)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:A
Last Name:GAGLIARDI
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:A
Other - Last Name:MOKRZYCKI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:15200 GRATIOT
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48205
Mailing Address - Country:US
Mailing Address - Phone:313-924-8495
Mailing Address - Fax:313-924-8472
Practice Address - Street 1:15200 GRATIOT
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48205
Practice Address - Country:US
Practice Address - Phone:313-924-8495
Practice Address - Fax:313-924-8472
Is Sole Proprietor?:No
Enumeration Date:2015-08-18
Last Update Date:2024-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704278477163WC0200X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163WC0200XNursing Service ProvidersRegistered NurseCritical Care Medicine