Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207R00000X | Internist | 4301092531 | MI |
Y | 111NI0900X | Internist | 4301092531 | MI |
NPI | 1003079088 |
---|---|
Provider Name | Nicole Marijanovich |
First Address | Royal Oak, MI 48073-6712 |
Second Address | Royal Oak, MI 48073-6712 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 09/07/2008 |
Last Update Date | 30/06/2011 |