MEDICARE: NICOLLE RENEE AHLES-MOSES APRN, CNP

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	363LP0200X	Pediatric Nurse Practitioner	CNP1814	MN

General Provider Information

NPI Number	:	1902006166
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	NICOLLE RENEE AHLES-MOSES APRN, CNP

Provider Business Mailing Address
First Line	:	10081 DOGWOOD ST NW STE 100
Second Line	:
City	:	COON RAPIDS
State	:	MN
Zip	:	55448-5282
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	10081 DOGWOOD ST NW STE 100
Second Line	:
City	:	COON RAPIDS
State	:	MN
Zip	:	55448-5282
Country	:	US
Telephone Number	:	763-783-3722
Fax Number	:

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

Provider Enumeration Date	:	07/24/2007
Last Update Date	:	03/17/2018

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