Provider Demographics
NPI:1528391174
Name:HALVERSON, NICOLE A (CRNA)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:A
Last Name:HALVERSON
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3701 12TH ST N
Mailing Address - Street 2:SUITE 202
Mailing Address - City:SAINT CLOUD
Mailing Address - State:MN
Mailing Address - Zip Code:56303-2255
Mailing Address - Country:US
Mailing Address - Phone:320-258-3090
Mailing Address - Fax:320-258-3095
Practice Address - Street 1:3701 12TH ST N
Practice Address - Street 2:SUITE 202
Practice Address - City:SAINT CLOUD
Practice Address - State:MN
Practice Address - Zip Code:56303-2255
Practice Address - Country:US
Practice Address - Phone:320-258-3090
Practice Address - Fax:320-258-3095
Is Sole Proprietor?:No
Enumeration Date:2009-09-15
Last Update Date:2010-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR147876-7367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1528391174Medicaid
MN430006944Medicare PIN