MEDICARE: NANCY A NICKLE RNCNP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LW0102X	Women's Health Nurse Practitioner	44603	CO
2	363LX0001X	Obstetrics & Gynecology Nurse Practitioner	44603	CO

General Provider Information

NPI Number	:	1275624314
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	NANCY A NICKLE RNCNP

Provider Business Mailing Address
First Line	:	916 LAKE ST
Second Line	:
City	:	FORT MORGAN
State	:	CO
Zip	:	80701-3029
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	916 LAKE ST
Second Line	:
City	:	FORT MORGAN
State	:	CO
Zip	:	80701-3029
Country	:	US
Telephone Number	:	303-232-3675
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/27/2006
Last Update Date	:	07/10/2007

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