Provider Demographics
NPI:1669812459
Name:BUSCH, NICOLE MARIE (FNP-BC)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:MARIE
Last Name:BUSCH
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:MARIE
Other - Last Name:WARD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:912 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:LITTLEFORK
Mailing Address - State:MN
Mailing Address - Zip Code:56653-9357
Mailing Address - Country:US
Mailing Address - Phone:218-278-6634
Mailing Address - Fax:218-278-6637
Practice Address - Street 1:912 MAIN ST
Practice Address - Street 2:
Practice Address - City:LITTLEFORK
Practice Address - State:MN
Practice Address - Zip Code:56653-9357
Practice Address - Country:US
Practice Address - Phone:218-278-6634
Practice Address - Fax:218-278-6637
Is Sole Proprietor?:No
Enumeration Date:2013-06-26
Last Update Date:2015-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNCNP 2635363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNR143402-8OtherMINNESOTA RN LICENSE NUMBER
MNCNP 2635OtherAPRN LICENSE NUMBER
MNR143402-8OtherMINNESOTA RN LICENSE NUMBER