Provider Demographics
NPI:1437103959
Name:SICKELS, ROBIN J (LRD)
Entity Type:Individual
Prefix:
First Name:ROBIN
Middle Name:J
Last Name:SICKELS
Suffix:
Gender:F
Credentials:LRD
Other - Prefix:
Other - First Name:ROBIN
Other - Middle Name:
Other - Last Name:IVERSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:737 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58122-0001
Mailing Address - Country:US
Mailing Address - Phone:701-234-6339
Mailing Address - Fax:701-234-6085
Practice Address - Street 1:737 BROADWAY
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58122-0001
Practice Address - Country:US
Practice Address - Phone:701-234-6339
Practice Address - Fax:701-234-6085
Is Sole Proprietor?:No
Enumeration Date:2006-05-20
Last Update Date:2009-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND610133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND51127Medicaid
ND51127Medicaid