Provider Demographics
NPI:1568985257
Name:BUATALA, NICOLE SZUDY (RN, MSN, FNP, PMHNP)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:SZUDY
Last Name:BUATALA
Suffix:
Gender:F
Credentials:RN, MSN, FNP, PMHNP
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:MARIE
Other - Last Name:SZUDY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:9331 CAMBRIDGE RD
Mailing Address - Street 2:
Mailing Address - City:WOODBURY
Mailing Address - State:MN
Mailing Address - Zip Code:55125-9036
Mailing Address - Country:US
Mailing Address - Phone:218-851-5610
Mailing Address - Fax:
Practice Address - Street 1:1801 AMERICAN BLVD E
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:MN
Practice Address - Zip Code:55425-1232
Practice Address - Country:US
Practice Address - Phone:612-253-1111
Practice Address - Fax:952-767-0782
Is Sole Proprietor?:No
Enumeration Date:2017-07-25
Last Update Date:2024-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN5299363LF0000X, 363LP0808X
WI9918363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily