Provider Demographics
NPI:1407131063
Name:HASSEBROEK, NICHOLE J (CNP)
Entity Type:Individual
Prefix:
First Name:NICHOLE
Middle Name:J
Last Name:HASSEBROEK
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:PO BOX 5074
Mailing Address - Street 2:
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57117-5074
Mailing Address - Country:US
Mailing Address - Phone:605-328-6585
Mailing Address - Fax:605-312-9802
Practice Address - Street 1:1233 34TH ST NW
Practice Address - Street 2:
Practice Address - City:BEMIDJI
Practice Address - State:MN
Practice Address - Zip Code:56601-5112
Practice Address - Country:US
Practice Address - Phone:218-333-5522
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-10-14
Last Update Date:2023-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SDCP000666363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner