Provider Demographics
NPI:1144758160
Name:DICKERHOFF, NICOLETTE MARLENE
Entity type:Individual
Prefix:
First Name:NICOLETTE
Middle Name:MARLENE
Last Name:DICKERHOFF
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:NICOLETTE
Other - Middle Name:MARLENE
Other - Last Name:RIEGER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1534 VALE PL
Mailing Address - Street 2:
Mailing Address - City:ERIE
Mailing Address - State:CO
Mailing Address - Zip Code:80516-4037
Mailing Address - Country:US
Mailing Address - Phone:636-751-5771
Mailing Address - Fax:
Practice Address - Street 1:3200 PROVIDENCE DR
Practice Address - Street 2:
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99508-4615
Practice Address - Country:US
Practice Address - Phone:907-562-2211
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-03
Last Update Date:2017-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO1628334163WN0002X
AK124870363LN0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LN0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerNeonatal
No163WN0002XNursing Service ProvidersRegistered NurseNeonatal Intensive Care