Healthcare Provider Details

I. General information

NPI: 1477964336
Provider Name (Legal Business Name): NICOLE ANDERSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/14/2014
Last Update Date: 07/03/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5366 386TH ST NE
NORTH BRANCH MN
55056-5833
US

IV. Provider business mailing address

9778 PINE SHORES DR
PINE CITY MN
55063-4575
US

V. Phone/Fax

Practice location:
  • Phone: 651-674-8353
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberAG0614167
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberR1795291
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: