Healthcare Provider Details

I. General information

NPI: 1164569760
Provider Name (Legal Business Name): BETTY NICHOLS RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/31/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17230 NOOPIMING DR.
ONAIMA MN
56359
US

IV. Provider business mailing address

17230 NOOPIMING DR.
ONAIMA MN
56359
US

V. Phone/Fax

Practice location:
  • Phone: 310-532-7511
  • Fax: 320-532-7524
Mailing address:
  • Phone: 310-532-7511
  • Fax: 320-532-7524

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberR 111515-6
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: