Provider Demographics
NPI:1033264585
Name:HAAKE, ERICA LEE NICKESON (MD)
Entity Type:Individual
Prefix:
First Name:ERICA
Middle Name:LEE NICKESON
Last Name:HAAKE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:ERICA
Other - Middle Name:L
Other - Last Name:NICKESON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:2444 W FAIDLEY AVE
Mailing Address - Street 2:P O BOX 550
Mailing Address - City:GRAND ISLAND
Mailing Address - State:NE
Mailing Address - Zip Code:68803-4327
Mailing Address - Country:US
Mailing Address - Phone:308-382-1100
Mailing Address - Fax:308-385-0796
Practice Address - Street 1:2444 W FAIDLEY AVE
Practice Address - Street 2:
Practice Address - City:GRAND ISLAND
Practice Address - State:NE
Practice Address - Zip Code:68803-4327
Practice Address - Country:US
Practice Address - Phone:308-382-1100
Practice Address - Fax:308-385-0796
Is Sole Proprietor?:No
Enumeration Date:2007-01-24
Last Update Date:2023-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK25132207V00000X
NE25657207VX0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VX0000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyObstetrics
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NECO4245OtherRR MEDICARE
NE47017633016Medicaid
NE098172004Medicare PIN
NE47017633016Medicaid