Provider Demographics
NPI:1346618923
Name:NICKLAY, MARY JOANNE (CNP)
Entity Type:Individual
Prefix:MRS
First Name:MARY
Middle Name:JOANNE
Last Name:NICKLAY
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 1:520 1ST AVE NE
Mailing Address - Street 2:
Mailing Address - City:BYRON
Mailing Address - State:MN
Mailing Address - Zip Code:55920-1422
Mailing Address - Country:US
Mailing Address - Phone:507-951-9935
Mailing Address - Fax:
Practice Address - Street 1:520 1ST AVE NE
Practice Address - Street 2:
Practice Address - City:BYRON
Practice Address - State:MN
Practice Address - Zip Code:55920-1422
Practice Address - Country:US
Practice Address - Phone:507-951-9935
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-09-13
Last Update Date:2024-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR188315-8363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner