Healthcare Provider Details

I. General information

NPI: 1780243691
Provider Name (Legal Business Name): NICOLE HARRIS OD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/13/2019
Last Update Date: 12/30/2021
Certification Date: 12/30/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2950 CURVE CREST BLVD W
STILLWATER MN
55082-5085
US

IV. Provider business mailing address

1719 TOWER DR W STE 100
STILLWATER MN
55082-7512
US

V. Phone/Fax

Practice location:
  • Phone: 651-275-3028
  • Fax:
Mailing address:
  • Phone: 651-275-3050
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number3620
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: