Provider Demographics
NPI:1073689295
Name:NICKLAS, NICOLLE MARIE (CRNA)
Entity Type:Individual
Prefix:
First Name:NICOLLE
Middle Name:MARIE
Last Name:NICKLAS
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15642 COBBLESTONE LAKE PKWY
Mailing Address - Street 2:
Mailing Address - City:APPLE VALLEY
Mailing Address - State:MN
Mailing Address - Zip Code:55124-7829
Mailing Address - Country:US
Mailing Address - Phone:763-439-7831
Mailing Address - Fax:
Practice Address - Street 1:219 GARDEN ST.
Practice Address - Street 2:
Practice Address - City:DULUTH
Practice Address - State:MN
Practice Address - Zip Code:55812
Practice Address - Country:US
Practice Address - Phone:763-439-7831
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-28
Last Update Date:2009-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR130252-9367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS200613280AMedicaid
MN368410500Medicaid
KS200613280AMedicaid
KS110017036Medicare PIN