Healthcare Provider Details

I. General information

NPI: 1699395582
Provider Name (Legal Business Name): NICOLE MARIE SIEBEN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/21/2020
Last Update Date: 11/18/2024
Certification Date: 11/18/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

203 PARK AVE S STE 101
SAINT CLOUD MN
56301-6216
US

IV. Provider business mailing address

708 N JUNIPER ST
ROYALTON MN
56373-9131
US

V. Phone/Fax

Practice location:
  • Phone: 320-253-5650
  • Fax: 320-253-9222
Mailing address:
  • Phone: 320-232-8844
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: