Provider Demographics
NPI:1063500791
Name:ENZMINGER, NICOLE A (LRD)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:A
Last Name:ENZMINGER
Suffix:
Gender:F
Credentials:LRD
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:A
Other - Last Name:MCKENZIE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LRD
Mailing Address - Street 1:PO BOX 5501
Mailing Address - Street 2:
Mailing Address - City:BISMARCK
Mailing Address - State:ND
Mailing Address - Zip Code:58506-5501
Mailing Address - Country:US
Mailing Address - Phone:701-323-6000
Mailing Address - Fax:701-323-5709
Practice Address - Street 1:222 N 7TH ST
Practice Address - Street 2:
Practice Address - City:BISMARCK
Practice Address - State:ND
Practice Address - Zip Code:58501-4436
Practice Address - Country:US
Practice Address - Phone:701-323-6000
Practice Address - Fax:701-323-5709
Is Sole Proprietor?:No
Enumeration Date:2006-10-10
Last Update Date:2007-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND487133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND50684Medicaid
ND50684Medicaid