Provider Demographics
NPI:1760623771
Name:NICHOLSON, SHIRLEY ANN
Entity Type:Individual
Prefix:
First Name:SHIRLEY
Middle Name:ANN
Last Name:NICHOLSON
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 1:307 2ND AVE
Mailing Address - Street 2:
Mailing Address - City:TWO HARBORS
Mailing Address - State:MN
Mailing Address - Zip Code:55616-1619
Mailing Address - Country:US
Mailing Address - Phone:218-834-2172
Mailing Address - Fax:218-834-2172
Practice Address - Street 1:307 2ND AVE
Practice Address - Street 2:
Practice Address - City:TWO HARBORS
Practice Address - State:MN
Practice Address - Zip Code:55616-1619
Practice Address - Country:US
Practice Address - Phone:218-834-2172
Practice Address - Fax:218-834-2172
Is Sole Proprietor?:Yes
Enumeration Date:2009-03-20
Last Update Date:2009-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN230534-1-AFC172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker