Healthcare Provider Details

I. General information

NPI: 1568646057
Provider Name (Legal Business Name): NICOLE M CHASE MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: NICOLE M COLLINS MD

II. Dates (important events)

Enumeration Date: 12/20/2007
Last Update Date: 07/05/2021
Certification Date: 07/05/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

565 SNELLING AVE S
SAINT PAUL MN
55116-1525
US

IV. Provider business mailing address

565 SNELLING AVE S
SAINT PAUL MN
55116-1525
US

V. Phone/Fax

Practice location:
  • Phone: 651-698-0386
  • Fax: 651-698-0483
Mailing address:
  • Phone: 651-698-0386
  • Fax: 651-698-0483

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number52838
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number232221
License Number StateMA
# 3
Primary TaxonomyY
Taxonomy Code207K00000X
TaxonomyAllergy & Immunology Physician
License Number55037
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: