MEDICARE: MRS. NICOLE DENISE MOLLMAN

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	246X00000X	Cardiovascular Specialist/Technologist

General Provider Information

NPI Number	:	1427367176
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. NICOLE DENISE MOLLMAN

Provider Business Mailing Address
First Line	:	PO BOX 317
Second Line	:
City	:	BLACK HAWK
State	:	SD
Zip	:	57718-0317
Country	:	US
Telephone Number	:	605-721-4800
Fax Number	:	605-721-4836

Provider Business Practice Location Address
First Line	:	215 ANAMARIA DR STE 133
Second Line	:
City	:	RAPID CITY
State	:	SD
Zip	:	57701-7376
Country	:	US
Telephone Number	:	605-721-4800
Fax Number	:	605-721-4836

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

Provider Enumeration Date	:	09/29/2010
Last Update Date	:	11/28/2016

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