Provider Demographics
NPI:1790020204
Name:NICKOLI, MISTY MORNA (LPN)
Entity Type:Individual
Prefix:
First Name:MISTY
Middle Name:MORNA
Last Name:NICKOLI
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:MISTY
Other - Middle Name:MORNA
Other - Last Name:GIL-MARTINEZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LPN
Mailing Address - Street 1:1717 WEST COWELS STREET
Mailing Address - Street 2:
Mailing Address - City:FAIRBANKS
Mailing Address - State:AK
Mailing Address - Zip Code:99701
Mailing Address - Country:US
Mailing Address - Phone:907-451-6682
Mailing Address - Fax:907-459-3950
Practice Address - Street 1:1717 WEST COWELS STREET
Practice Address - Street 2:
Practice Address - City:FAIRBANKS
Practice Address - State:AK
Practice Address - Zip Code:99701
Practice Address - Country:US
Practice Address - Phone:907-451-6682
Practice Address - Fax:907-459-3950
Is Sole Proprietor?:Yes
Enumeration Date:2012-12-10
Last Update Date:2012-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK6776164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse