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General NPI Number Information
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NPI Number | 1093781452
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Entity Type | Individual
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Provider Name | GLENN A NICKELE MD
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Gender | Male
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Dates
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Enumeration Date | 02/27/2006
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Last Update Date | 06/12/2024
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Provider Practice Location Address
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Address Line | 216 S ADAMS ST
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City | SAINT CROIX FALLS
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State | WI
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Zip | 54024-9449
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Country | US
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Telephone | 715-483-3221
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Fax | 715-483-0507
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Provider Business Mailing Address
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Address Line | 235 STATE STREET
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City | ST. CROIX FALLS
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State | WI
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Zip | 54024-4117
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Country | US
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Telephone | 715-483-3261
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Fax | 715-483-0507
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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 | 207RC0000X
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Taxonomy Name | Cardiovascular Disease Physician
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License Number | 42548
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License Number State | MN
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Taxonomy #2
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Taxonomy Code | 207RC0000X
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Taxonomy Name | Cardiovascular Disease Physician
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License Number | 32220
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License Number State | WI
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