Healthcare Provider Details

I. General information

NPI: 1710162680
Provider Name (Legal Business Name): NICOLE CARLA IAMMATTEO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: NICOLE IAMMATTEO LINDSTROM MS, OTR/L

II. Dates (important events)

Enumeration Date: 01/09/2008
Last Update Date: 09/16/2026
Certification Date: 09/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3455 153RD ST W
ROSEMOUNT MN
55068-4946
US

IV. Provider business mailing address

4058 DEERWOOD TRL
EAGAN MN
55122-1889
US

V. Phone/Fax

Practice location:
  • Phone: 651-423-7700
  • Fax:
Mailing address:
  • Phone: 651-994-9644
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number102786
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: