Provider Demographics
NPI:1619249075
Name:GILBERTSON, NICHOLLE MARIE (MSPT)
Entity Type:Individual
Prefix:
First Name:NICHOLLE
Middle Name:MARIE
Last Name:GILBERTSON
Suffix:
Gender:F
Credentials:MSPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:123 FOREST AVE
Mailing Address - Street 2:
Mailing Address - City:VERMILLION
Mailing Address - State:SD
Mailing Address - Zip Code:57069-3107
Mailing Address - Country:US
Mailing Address - Phone:605-670-0338
Mailing Address - Fax:605-624-2992
Practice Address - Street 1:123 FOREST AVE
Practice Address - Street 2:
Practice Address - City:VERMILLION
Practice Address - State:SD
Practice Address - Zip Code:57069-3107
Practice Address - Country:US
Practice Address - Phone:605-670-0338
Practice Address - Fax:605-624-2992
Is Sole Proprietor?:Yes
Enumeration Date:2012-02-01
Last Update Date:2012-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD1113314000000X
IA13217314000000X
NE2522314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility