Provider Demographics
NPI:1588184394
Name:STEVENSON, NICOLE
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:STEVENSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10764 7TH ST NE
Mailing Address - Street 2:
Mailing Address - City:BLAINE
Mailing Address - State:MN
Mailing Address - Zip Code:55434-1644
Mailing Address - Country:US
Mailing Address - Phone:763-350-7860
Mailing Address - Fax:
Practice Address - Street 1:1611 COUNTY ROAD 10
Practice Address - Street 2:
Practice Address - City:SPRING LAKE PARK
Practice Address - State:MN
Practice Address - Zip Code:55432-2124
Practice Address - Country:US
Practice Address - Phone:763-784-1540
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-22
Last Update Date:2017-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist