Provider Demographics
NPI:1164070397
Name:DE VERA, NICOLE JEAN
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:JEAN
Last Name:DE VERA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3253 19TH ST NW STE 1
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:MN
Mailing Address - Zip Code:55901-6794
Mailing Address - Country:US
Mailing Address - Phone:507-218-2424
Mailing Address - Fax:
Practice Address - Street 1:3253 19TH ST NW STE 1
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:MN
Practice Address - Zip Code:55901-6794
Practice Address - Country:US
Practice Address - Phone:507-218-2424
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-30
Last Update Date:2019-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty