Provider Demographics
NPI:1740578699
Name:WEIERS, NICOLE
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:WEIERS
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 1:6700 FRANCE AVE S
Mailing Address - Street 2:SUITE 230
Mailing Address - City:EDINA
Mailing Address - State:MN
Mailing Address - Zip Code:55435-1902
Mailing Address - Country:US
Mailing Address - Phone:952-908-2700
Mailing Address - Fax:
Practice Address - Street 1:6700 FRANCE AVE S
Practice Address - Street 2:SUITE 230
Practice Address - City:EDINA
Practice Address - State:MN
Practice Address - Zip Code:55435-1902
Practice Address - Country:US
Practice Address - Phone:952-908-2700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-07-13
Last Update Date:2014-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN8778225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN8778OtherLICENSE