Provider Demographics
NPI:1275168619
Name:CHOMILO, NICOLINE
Entity Type:Individual
Prefix:
First Name:NICOLINE
Middle Name:
Last Name:CHOMILO
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 1:4355 KADY AVE NE
Mailing Address - Street 2:
Mailing Address - City:SAINT MICHAEL
Mailing Address - State:MN
Mailing Address - Zip Code:55376-8498
Mailing Address - Country:US
Mailing Address - Phone:763-291-5198
Mailing Address - Fax:
Practice Address - Street 1:4355 KADY AVE NE
Practice Address - Street 2:
Practice Address - City:SAINT MICHAEL
Practice Address - State:MN
Practice Address - Zip Code:55376-8498
Practice Address - Country:US
Practice Address - Phone:761-291-5198
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-05
Last Update Date:2020-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1493108163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse