Provider Demographics
NPI:1417387093
Name:RAYMO, NICHOLAS (HIS)
Entity Type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:
Last Name:RAYMO
Suffix:
Gender:M
Credentials:HIS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1700 S SHORE DR
Mailing Address - Street 2:
Mailing Address - City:WORTHINGTON
Mailing Address - State:MN
Mailing Address - Zip Code:56187-1353
Mailing Address - Country:US
Mailing Address - Phone:507-360-0140
Mailing Address - Fax:
Practice Address - Street 1:1700 S SHORE DR
Practice Address - Street 2:
Practice Address - City:WORTHINGTON
Practice Address - State:MN
Practice Address - Zip Code:56187-1353
Practice Address - Country:US
Practice Address - Phone:507-360-0140
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-11-19
Last Update Date:2018-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA1020237700000X
MN2720237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist