=====================================================
General NPI Number Information
=====================================================
NPI Number | 1659886448
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JAN MARIE NICODEMUS
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/04/2017
-----------------------------------------------------
Last Update Date | 07/21/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 12950 FREMONT AVE STE 102
-----------------------------------------------------
City | ZIMMERMAN
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55398-4629
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 763-294-0714
-----------------------------------------------------
Fax | 763-374-7161
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 12950 FREMONT AVE STE 102
-----------------------------------------------------
City | ZIMMERMAN
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55398-4629
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 763-294-0714
-----------------------------------------------------
Fax | 763-374-7161
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 374U00000X
-----------------------------------------------------
Taxonomy Name | Home Health Aide
-----------------------------------------------------
License Number | 10704477
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------