Provider Demographics
NPI:1619563178
Name:O'NEILL, NICOLE LYN
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:LYN
Last Name:O'NEILL
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 1:401 SIGRID DR
Mailing Address - Street 2:
Mailing Address - City:BUFFALO
Mailing Address - State:MN
Mailing Address - Zip Code:55313-1259
Mailing Address - Country:US
Mailing Address - Phone:763-688-0660
Mailing Address - Fax:
Practice Address - Street 1:6050 MAIN ST APT 101
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:MN
Practice Address - Zip Code:55373-4537
Practice Address - Country:US
Practice Address - Phone:763-515-3088
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-17
Last Update Date:2020-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN11994225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist