Healthcare Provider Details

I. General information

NPI: 1750942595
Provider Name (Legal Business Name): NICOLE MARIE GENSICKE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: NICOLE MARIE WESTERGARD

II. Dates (important events)

Enumeration Date: 06/24/2019
Last Update Date: 08/12/2024
Certification Date: 08/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

202 10TH ST SE
CEDAR RAPIDS IA
52403-2414
US

IV. Provider business mailing address

202 10TH ST SE
CEDAR RAPIDS IA
52403-2414
US

V. Phone/Fax

Practice location:
  • Phone: 319-247-3049
  • Fax:
Mailing address:
  • Phone: 712-249-2461
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License NumberR-11698
License Number StateIA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: