Provider Demographics
NPI:1780036517
Name:NICOLAISEN, IBID M (NP)
Entity Type:Individual
Prefix:
First Name:IBID
Middle Name:M
Last Name:NICOLAISEN
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:75-5751 KUAKINI HWY STE 203
Mailing Address - Street 2:
Mailing Address - City:KAILUA KONA
Mailing Address - State:HI
Mailing Address - Zip Code:96740-1753
Mailing Address - Country:US
Mailing Address - Phone:808-326-5629
Mailing Address - Fax:
Practice Address - Street 1:81-980 HALEKII ST STE 107
Practice Address - Street 2:
Practice Address - City:KEALAKEKUA
Practice Address - State:HI
Practice Address - Zip Code:96750-8177
Practice Address - Country:US
Practice Address - Phone:808-324-0703
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-07-05
Last Update Date:2021-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAA117690363LF0000X
HIAPRN-2139363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily