Healthcare Provider Details

I. General information

NPI: 1386811552
Provider Name (Legal Business Name): NICOLE E WILEY LISW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/15/2008
Last Update Date: 09/22/2026
Certification Date: 09/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2270 FORD PKWY STE 106
SAINT PAUL MN
55116-3412
US

IV. Provider business mailing address

1730 GRAHAM AVE # B151
SAINT PAUL MN
55116-3090
US

V. Phone/Fax

Practice location:
  • Phone: 612-915-0049
  • Fax: 620-926-1450
Mailing address:
  • Phone: 702-237-7739
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number29269
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberI.1000113
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: