Provider Demographics
NPI:1043702244
Name:BAMBERG, NICOLE LYNN (CNP)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:LYNN
Last Name:BAMBERG
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:708 8TH ST
Mailing Address - Street 2:
Mailing Address - City:ARMOUR
Mailing Address - State:SD
Mailing Address - Zip Code:57313-2102
Mailing Address - Country:US
Mailing Address - Phone:605-724-2159
Mailing Address - Fax:605-724-2310
Practice Address - Street 1:265 E MAIN ST
Practice Address - Street 2:
Practice Address - City:CORSICA
Practice Address - State:SD
Practice Address - Zip Code:57328
Practice Address - Country:US
Practice Address - Phone:605-946-5959
Practice Address - Fax:605-946-5616
Is Sole Proprietor?:No
Enumeration Date:2018-06-04
Last Update Date:2018-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SDCP001381363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner