Provider Demographics
NPI:1336499904
Name:PELACH, NICOLE RAE (NP)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:RAE
Last Name:PELACH
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:RAE
Other - Last Name:TABATT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:720 WASHINGTON AVE SE STE 300
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55414-2904
Mailing Address - Country:US
Mailing Address - Phone:612-672-7422
Mailing Address - Fax:612-884-0907
Practice Address - Street 1:2200 NW 26TH ST
Practice Address - Street 2:
Practice Address - City:OWATONNA
Practice Address - State:MN
Practice Address - Zip Code:55060-5503
Practice Address - Country:US
Practice Address - Phone:507-451-1120
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-09-11
Last Update Date:2022-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR 130266-8363LF0000X
MN1207363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily