Healthcare Provider Details

I. General information

NPI: 1316581440
Provider Name (Legal Business Name): NORTHERN LIGHTS HEALTH LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/31/2019
Last Update Date: 12/22/2019
Certification Date: 12/22/2019
Deactivation Date:
Reactivation Date:

III. Provider practice location address

212 W LAKE ST
WACONIA MN
55387-1014
US

IV. Provider business mailing address

212 W LAKE ST
WACONIA MN
55387-1014
US

V. Phone/Fax

Practice location:
  • Phone: 920-217-9035
  • Fax:
Mailing address:
  • Phone: 920-217-9035
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: NICOLE M SIDDONS
Title or Position: CO-FOUNDER
Credential: FNP-C
Phone: 920-217-9035