Provider Demographics
NPI:1558387589
Name:BINGHAM, NICOLE MARIE (DC)
Entity Type:Individual
Prefix:DR
First Name:NICOLE
Middle Name:MARIE
Last Name:BINGHAM
Suffix:
Gender:F
Credentials:DC
Other - Prefix:DR
Other - First Name:NICOLE
Other - Middle Name:MARIE
Other - Last Name:KETELSEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DC
Mailing Address - Street 1:206 COLLINS RD NE
Mailing Address - Street 2:STE 102
Mailing Address - City:CEDAR RAPIDS
Mailing Address - State:IA
Mailing Address - Zip Code:52402-3165
Mailing Address - Country:US
Mailing Address - Phone:319-373-7576
Mailing Address - Fax:
Practice Address - Street 1:206 COLLINS RD NE
Practice Address - Street 2:STE 102
Practice Address - City:CEDAR RAPIDS
Practice Address - State:IA
Practice Address - Zip Code:52402-3165
Practice Address - Country:US
Practice Address - Phone:319-373-7576
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAA06142111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA49489OtherBLUE CROSS BLUE SHIELD
IAP00095233OtherRAILROAD MEDICARE
IA0262220Medicaid
IA15709OtherMIDLANDS CHOICE
IA91957OtherAMER WHOLE HEALTH NETWORK
IA902320OtherUSA MCO NETWORK
IA15709OtherMIDLANDS CHOICE