Healthcare Provider Details

I. General information

NPI: 1629314075
Provider Name (Legal Business Name): NICOLE M DONAGER CNM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: NICOLE M TERWILLIGER CNM

II. Dates (important events)

Enumeration Date: 12/12/2012
Last Update Date: 07/22/2024
Certification Date: 07/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 LAGOON AVE
MINNEAPOLIS MN
55408-2077
US

IV. Provider business mailing address

1200 LAGOON AVE
MINNEAPOLIS MN
55408-2077
US

V. Phone/Fax

Practice location:
  • Phone: 917-882-0934
  • Fax:
Mailing address:
  • Phone: 917-882-0934
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code176B00000X
TaxonomyMidwife
License Number176312
License Number StateMT
# 2
Primary TaxonomyN
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number176312
License Number StateMT
# 3
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number11700
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: