Healthcare Provider Details

I. General information

NPI: 1083441240
Provider Name (Legal Business Name): NICHOLE RAE LEBLANC RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/19/2024
Last Update Date: 03/25/2026
Certification Date: 03/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

722 NW 7TH ST
BRAINERD MN
56401-2912
US

IV. Provider business mailing address

722 NW 7TH STREET COMMUNITY BASES OUTREACH CLINIC
BRAINERD MN
56401
US

V. Phone/Fax

Practice location:
  • Phone: 218-825-2621
  • Fax:
Mailing address:
  • Phone: 218-825-2621
  • Fax: 612-725-1302

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP2201X
TaxonomyAmbulatory Care Registered Nurse
License Number2206491
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: