Provider Demographics
NPI:1518744499
Name:NICHOLS, MARISA LEIGH (PA-C)
Entity type:Individual
Prefix:
First Name:MARISA
Middle Name:LEIGH
Last Name:NICHOLS
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:MARISA
Other - Middle Name:LEIGH
Other - Last Name:PSZCZOLKOWSKI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:9919 BERWYN
Mailing Address - Street 2:
Mailing Address - City:REDFORD
Mailing Address - State:MI
Mailing Address - Zip Code:48239-2120
Mailing Address - Country:US
Mailing Address - Phone:734-386-9425
Mailing Address - Fax:
Practice Address - Street 1:23077 GREENFIELD RD STE 253
Practice Address - Street 2:
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48075-3750
Practice Address - Country:US
Practice Address - Phone:248-559-5950
Practice Address - Fax:248-559-2103
Is Sole Proprietor?:No
Enumeration Date:2023-09-13
Last Update Date:2025-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601012050363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant