Provider Demographics
NPI:1720367840
Name:WHITE, NICOLE JACQUELINE (RN, MS, CPNP)
Entity Type:Individual
Prefix:MRS
First Name:NICOLE
Middle Name:JACQUELINE
Last Name:WHITE
Suffix:
Gender:F
Credentials:RN, MS, CPNP
Other - Prefix:
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Mailing Address - Street 1:PO BOX 6010
Mailing Address - Street 2:
Mailing Address - City:GREAT FALLS
Mailing Address - State:MT
Mailing Address - Zip Code:59406-6010
Mailing Address - Country:US
Mailing Address - Phone:406-731-8888
Mailing Address - Fax:406-731-8318
Practice Address - Street 1:25 14TH AVE NW
Practice Address - Street 2:
Practice Address - City:GREAT FALLS
Practice Address - State:MT
Practice Address - Zip Code:59404
Practice Address - Country:US
Practice Address - Phone:406-731-8888
Practice Address - Fax:406-731-8318
Is Sole Proprietor?:No
Enumeration Date:2011-08-07
Last Update Date:2024-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT48237363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT1720367840Medicaid
MTM011002672Medicare PIN