Healthcare Provider Details

I. General information

NPI: 1902436033
Provider Name (Legal Business Name): NICOLE LANDEN CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: NICOLE SCHUMACHER

II. Dates (important events)

Enumeration Date: 01/16/2020
Last Update Date: 01/16/2020
Certification Date: 01/16/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5225 23RD AVE S
FARGO ND
58104-7927
US

IV. Provider business mailing address

3559 8TH ST E
WEST FARGO ND
58078-5423
US

V. Phone/Fax

Practice location:
  • Phone: 701-417-2000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberR40421
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: