Provider Demographics
NPI:1689011462
Name:BAKER, NICOLE (MD)
Entity Type:Individual
Prefix:DR
First Name:NICOLE
Middle Name:
Last Name:BAKER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:90 HOPE DRIVE
Mailing Address - Street 2:366 MDG/SGXW
Mailing Address - City:MOUNTAIN HOME AFB
Mailing Address - State:ID
Mailing Address - Zip Code:83648-1057
Mailing Address - Country:US
Mailing Address - Phone:208-828-7580
Mailing Address - Fax:
Practice Address - Street 1:90 HOPE DRIVE
Practice Address - Street 2:366 MDG/SGXW
Practice Address - City:MOUNTAIN HOME AFB
Practice Address - State:ID
Practice Address - Zip Code:83648-1057
Practice Address - Country:US
Practice Address - Phone:208-828-7580
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-03
Last Update Date:2022-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH390200000X
NE290872084P0805X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0805XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyGeriatric PsychiatryGroup - Single Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE29087OtherSTATE OF NEBRASKA DEPT. OF HHS, DIVISION OF PUBLIC HEALTH
OHACKNOWLEDGEMENT LETTOtherOHIO STATE MEDCAL BOARD