Healthcare Provider Details

I. General information

NPI: 1457778623
Provider Name (Legal Business Name): NICOLE KALAMITSIOTIS AGACNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: NICOLE MORTON

II. Dates (important events)

Enumeration Date: 03/25/2014
Last Update Date: 01/02/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1700 UNIVERSITY AVE W FL 6
SAINT PAUL MN
55104
US

IV. Provider business mailing address

1690 UNIVERSITY AVE W STE 370
SAINT PAUL MN
55104-3723
US

V. Phone/Fax

Practice location:
  • Phone: 651-232-6905
  • Fax: 651-326-8170
Mailing address:
  • Phone: 651-232-6905
  • Fax: 651-326-8170

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License Number2005008812
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number4504
License Number StateMN
# 3
Primary TaxonomyN
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number4504
License Number StateMN
# 4
Primary TaxonomyY
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License Number4504
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: