Healthcare Provider Details

I. General information

NPI: 1629487632
Provider Name (Legal Business Name): NICOLETTE MABB DNP, ARNP, PMHNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/05/2014
Last Update Date: 05/31/2022
Certification Date: 05/31/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

709 W MAIN ST
MANCHESTER IA
52057-1526
US

IV. Provider business mailing address

709 W MAIN ST
MANCHESTER IA
52057-1526
US

V. Phone/Fax

Practice location:
  • Phone: 563-927-7777
  • Fax:
Mailing address:
  • Phone: 563-927-7777
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number6249
License Number StateWI
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberG122642
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: