Provider Demographics
NPI:1558816306
Name:MONTICELLO, ERIC (APRN,CNP)
Entity Type:Individual
Prefix:
First Name:ERIC
Middle Name:
Last Name:MONTICELLO
Suffix:
Gender:M
Credentials:APRN,CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 E 3RD ST
Mailing Address - Street 2:
Mailing Address - City:DULUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55805-1951
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1300 SOUTH DRIVE
Practice Address - Street 2:
Practice Address - City:WINNEBAGO
Practice Address - State:WI
Practice Address - Zip Code:54985-5498
Practice Address - Country:US
Practice Address - Phone:920-235-4910
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-22
Last Update Date:2023-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NDR384922084P0800X, 363LP0808X
NC295229363LP0808X
WI80992084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health