Provider Demographics
NPI:1366931859
Name:OMELL, NICOLE TERESE DESAUTELS (MD)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:TERESE DESAUTELS
Last Name:OMELL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:43455 SCHOENHERR RD
Mailing Address - Street 2:
Mailing Address - City:STERLING HEIGHTS
Mailing Address - State:MI
Mailing Address - Zip Code:48313-1951
Mailing Address - Country:US
Mailing Address - Phone:586-726-4823
Mailing Address - Fax:
Practice Address - Street 1:43455 SCHOENHERR RD
Practice Address - Street 2:
Practice Address - City:STERLING HEIGHTS
Practice Address - State:MI
Practice Address - Zip Code:48313-1951
Practice Address - Country:US
Practice Address - Phone:586-726-4823
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-09
Last Update Date:2021-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301504302207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine