Provider Demographics
NPI:1275845547
Name:WILSON, NICOLE OLIVIA (NP)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:OLIVIA
Last Name:WILSON
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:OLIVIA
Other - Last Name:ENGSTROM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:914 1ST AVE SE
Mailing Address - Street 2:
Mailing Address - City:MINOT
Mailing Address - State:ND
Mailing Address - Zip Code:58701-4008
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:914 1ST AVE SE
Practice Address - Street 2:
Practice Address - City:MINOT
Practice Address - State:ND
Practice Address - Zip Code:58701-4008
Practice Address - Country:US
Practice Address - Phone:701-739-3094
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-07-02
Last Update Date:2015-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NDR31921363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health