Healthcare Provider Details

I. General information

NPI: 1669124756
Provider Name (Legal Business Name): NICOLE A SMITH FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: NICOLE A O'DELL FNP

II. Dates (important events)

Enumeration Date: 01/20/2022
Last Update Date: 10/08/2024
Certification Date: 10/08/2024
Deactivation Date: 09/24/2022
Reactivation Date: 10/05/2022

III. Provider practice location address

1804 7TH ST W STE 200
SAINT PAUL MN
55116-2300
US

IV. Provider business mailing address

3500 AMERICAN BLVD W STE 300
BLOOMINGTON MN
55431-4442
US

V. Phone/Fax

Practice location:
  • Phone: 651-227-7806
  • Fax: 651-256-6710
Mailing address:
  • Phone: 952-512-5600
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number243890-0
License Number StateMN
# 2
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number9561
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: