Provider Demographics
NPI:1215224092
Name:JENABZADEH, NICOLE MARIE (CNP)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:MARIE
Last Name:JENABZADEH
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 308
Mailing Address - Street 2:
Mailing Address - City:FOREST LAKE
Mailing Address - State:MN
Mailing Address - Zip Code:55025-0308
Mailing Address - Country:US
Mailing Address - Phone:952-807-0415
Mailing Address - Fax:952-236-6461
Practice Address - Street 1:130 CHESHIRE LN STE 100
Practice Address - Street 2:
Practice Address - City:MINNETONKA
Practice Address - State:MN
Practice Address - Zip Code:55305-0002
Practice Address - Country:US
Practice Address - Phone:952-807-0415
Practice Address - Fax:952-236-6461
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-30
Last Update Date:2022-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNF05111030363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily