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General NPI Number Information
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NPI Number | 1073689295
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Entity Type | Individual
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Provider Name | NICOLLE MARIE NICKLAS CRNA
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Gender | Female
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Dates
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Enumeration Date | 11/28/2006
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Last Update Date | 08/17/2009
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Provider Practice Location Address
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Address Line | 219 GARDEN ST.
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City | DULUTH
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State | MN
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Zip | 55812
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Country | US
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Telephone | 763-439-7831
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Fax |
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Provider Business Mailing Address
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Address Line | 15642 COBBLESTONE LAKE PKWY
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City | APPLE VALLEY
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State | MN
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Zip | 55124-7829
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Country | US
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Telephone | 763-439-7831
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 367500000X
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Taxonomy Name | Certified Registered Nurse Anesthetist
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License Number | R130252-9
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License Number State | MN
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