Provider Demographics
NPI:1659886448
Name:NICODEMUS, JAN MARIE
Entity Type:Individual
Prefix:
First Name:JAN
Middle Name:MARIE
Last Name:NICODEMUS
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 1:12950 FREMONT AVE STE 102
Mailing Address - Street 2:
Mailing Address - City:ZIMMERMAN
Mailing Address - State:MN
Mailing Address - Zip Code:55398-4629
Mailing Address - Country:US
Mailing Address - Phone:763-294-0714
Mailing Address - Fax:763-374-7161
Practice Address - Street 1:12950 FREMONT AVE STE 102
Practice Address - Street 2:
Practice Address - City:ZIMMERMAN
Practice Address - State:MN
Practice Address - Zip Code:55398-4629
Practice Address - Country:US
Practice Address - Phone:763-294-0714
Practice Address - Fax:763-374-7161
Is Sole Proprietor?:Yes
Enumeration Date:2017-12-04
Last Update Date:2024-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN383563253Z00000X, 374U00000X, 163WH0200X, 251E00000X
WY15416251B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes251E00000XAgenciesHome Health
No253Z00000XAgenciesIn Home Supportive CareGroup - Single Specialty
No374U00000XNursing Service Related ProvidersHome Health AideGroup - Single Specialty
No163WH0200XNursing Service ProvidersRegistered NurseHome HealthGroup - Single Specialty
No251B00000XAgenciesCase Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1083146344OtherSKILLED NURSING
MN1083146344OtherHOME HEALTH AGENCY
MN1083146344OtherPDN
WY1083146344OtherHOME HEALTH AGENCY