Provider Demographics
NPI:1407865223
Name:PICKETT, NANCY
Entity Type:Individual
Prefix:
First Name:NANCY
Middle Name:
Last Name:PICKETT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:715 E 78TH ST
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:MN
Mailing Address - Zip Code:55420-1397
Mailing Address - Country:US
Mailing Address - Phone:612-873-7644
Mailing Address - Fax:
Practice Address - Street 1:715 E 78TH ST
Practice Address - Street 2:HCMC WALMART RETAIL CLINIC-BLOOMINGTON
Practice Address - City:BLOOMINGTON
Practice Address - State:MN
Practice Address - Zip Code:55420-1397
Practice Address - Country:US
Practice Address - Phone:612-873-7644
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-08
Last Update Date:2013-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR 112160-3363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN233542500OtherMEDICAL ASSISTANCE
MN262R1PIOtherBLUE CROSS BLUE SHIELD
MNHP21020OtherHEALTHPARTNERS
MN0101848OtherMEDICA
MN6982979OtherEVERCARE
MN500000909Medicare ID - Type Unspecified