Provider Demographics
NPI:1164854188
Name:THEISEN, NICOLE (CRNA)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:THEISEN
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 1:3199 TIMBERWOLF CIR NW
Mailing Address - Street 2:
Mailing Address - City:PRIOR LAKE
Mailing Address - State:MN
Mailing Address - Zip Code:55372-3271
Mailing Address - Country:US
Mailing Address - Phone:612-860-6602
Mailing Address - Fax:
Practice Address - Street 1:3199 TIMBERWOLF CIR NW
Practice Address - Street 2:
Practice Address - City:PRIOR LAKE
Practice Address - State:MN
Practice Address - Zip Code:55372-3271
Practice Address - Country:US
Practice Address - Phone:612-860-6602
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-08-01
Last Update Date:2018-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR1718621367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered