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General NPI Number Information
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NPI Number | 1619563178
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Entity Type | Individual
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Provider Name | NICOLE LYN O'NEILL
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Gender | Female
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Dates
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Enumeration Date | 12/17/2020
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Last Update Date | 12/17/2020
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Provider Practice Location Address
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Address Line | 6050 MAIN ST APT 101
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City | ROCKFORD
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State | MN
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Zip | 55373-4537
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Country | US
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Telephone | 763-515-3088
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Fax |
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Provider Business Mailing Address
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Address Line | 401 SIGRID DR
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City | BUFFALO
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State | MN
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Zip | 55313-1259
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Country | US
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Telephone | 763-688-0660
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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 | 225100000X
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Taxonomy Name | Physical Therapist
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License Number | 11994
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License Number State | MN
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