Healthcare Provider Details

I. General information

NPI: 1619249075
Provider Name (Legal Business Name): NICHOLLE MARIE GILBERTSON MSPT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/01/2012
Last Update Date: 02/01/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

123 FOREST AVE
VERMILLION SD
57069-3107
US

IV. Provider business mailing address

123 FOREST AVE
VERMILLION SD
57069-3107
US

V. Phone/Fax

Practice location:
  • Phone: 605-670-0338
  • Fax: 605-624-2992
Mailing address:
  • Phone: 605-670-0338
  • Fax: 605-624-2992

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number1113
License Number StateSD
# 2
Primary TaxonomyN
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number13217
License Number StateIA
# 3
Primary TaxonomyN
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number2522
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: