Provider Demographics
NPI:1144083221
Name:WAWRA, NICOLE (LAC)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:WAWRA
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3340 NORTHDALE BLVD NW STE 120
Mailing Address - Street 2:
Mailing Address - City:COON RAPIDS
Mailing Address - State:MN
Mailing Address - Zip Code:55448-1622
Mailing Address - Country:US
Mailing Address - Phone:763-270-5828
Mailing Address - Fax:763-270-5849
Practice Address - Street 1:3340 NORTHDALE BLVD NW STE 120
Practice Address - Street 2:
Practice Address - City:COON RAPIDS
Practice Address - State:MN
Practice Address - Zip Code:55448-1622
Practice Address - Country:US
Practice Address - Phone:763-270-5828
Practice Address - Fax:763-270-5849
Is Sole Proprietor?:No
Enumeration Date:2024-02-01
Last Update Date:2024-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2071171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist