Healthcare Provider Details

I. General information

NPI: 1144758160
Provider Name (Legal Business Name): NICOLETTE MARLENE DICKERHOFF
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: NICOLETTE MARLENE RIEGER

II. Dates (important events)

Enumeration Date: 06/03/2017
Last Update Date: 10/11/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3200 PROVIDENCE DR
ANCHORAGE AK
99508-4615
US

IV. Provider business mailing address

1534 VALE PL
ERIE CO
80516-4037
US

V. Phone/Fax

Practice location:
  • Phone: 907-562-2211
  • Fax:
Mailing address:
  • Phone: 636-751-5771
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WN0002X
TaxonomyNeonatal Intensive Care Registered Nurse
License Number1628334
License Number StateCO
# 2
Primary TaxonomyY
Taxonomy Code363LN0000X
TaxonomyNeonatal Nurse Practitioner
License Number124870
License Number StateAK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: