Healthcare Provider Details

I. General information

NPI: 1881053056
Provider Name (Legal Business Name): NICOLE LEAND APRN, WHCNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: NICOLE LUND APRN, WHCNP

II. Dates (important events)

Enumeration Date: 02/17/2016
Last Update Date: 04/25/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1323 COON RAPIDS BLVD NW
COON RAPIDS MN
55433-5307
US

IV. Provider business mailing address

1323 COON RAPIDS BLVD NW
COON RAPIDS MN
55433-1312
US

V. Phone/Fax

Practice location:
  • Phone: 763-755-5300
  • Fax:
Mailing address:
  • Phone: 763-755-5300
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LW0102X
TaxonomyWomen's Health Nurse Practitioner
License NumberR 204103-8
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: