Provider Demographics
NPI:1851934863
Name:FELLERS, NICOLE LYNNE
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:LYNNE
Last Name:FELLERS
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 1:500 E COURT AVE
Mailing Address - Street 2:
Mailing Address - City:DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50309-2057
Mailing Address - Country:US
Mailing Address - Phone:515-237-3974
Mailing Address - Fax:515-237-3979
Practice Address - Street 1:2733 86TH ST
Practice Address - Street 2:
Practice Address - City:URBANDALE
Practice Address - State:IA
Practice Address - Zip Code:50322-4336
Practice Address - Country:US
Practice Address - Phone:515-987-5188
Practice Address - Fax:515-987-8152
Is Sole Proprietor?:No
Enumeration Date:2019-10-22
Last Update Date:2019-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAH118320363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner