Provider Demographics
NPI:1356657068
Name:ANDERSON, NICOLE MONIQUE (LPN)
Entity Type:Individual
Prefix:MS
First Name:NICOLE
Middle Name:MONIQUE
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10921 GRANTWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44108-3626
Mailing Address - Country:US
Mailing Address - Phone:216-527-8155
Mailing Address - Fax:
Practice Address - Street 1:10921 GRANTWOOD AVE
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44108-3626
Practice Address - Country:US
Practice Address - Phone:216-527-8155
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-19
Last Update Date:2010-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH121290164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
121290OtherOHIO BOARD OF NURSING