Provider Demographics
NPI:1427605021
Name:DIVELEY, NICOLE LINDY (PHARMD)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:LINDY
Last Name:DIVELEY
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:LINDY
Other - Last Name:RASMUSSEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:801 BELSLY BLVD
Mailing Address - Street 2:
Mailing Address - City:MOORHEAD
Mailing Address - State:MN
Mailing Address - Zip Code:56560-5055
Mailing Address - Country:US
Mailing Address - Phone:701-364-6800
Mailing Address - Fax:701-364-6828
Practice Address - Street 1:801 BELSLY BLVD
Practice Address - Street 2:
Practice Address - City:MOORHEAD
Practice Address - State:MN
Practice Address - Zip Code:56560-5055
Practice Address - Country:US
Practice Address - Phone:701-364-6800
Practice Address - Fax:701-364-6828
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-20
Last Update Date:2022-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD6669183500000X
MN12727183500000X
NDRPH6392183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist