Provider Demographics
NPI:1942804968
Name:EGSTAD, NICOLE
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:EGSTAD
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 1:449 HARVEY AVE
Mailing Address - Street 2:
Mailing Address - City:MINTO
Mailing Address - State:ND
Mailing Address - Zip Code:58261-6102
Mailing Address - Country:US
Mailing Address - Phone:701-314-0103
Mailing Address - Fax:
Practice Address - Street 1:2302 30TH AVE S APT 514
Practice Address - Street 2:
Practice Address - City:GRAND FORKS
Practice Address - State:ND
Practice Address - Zip Code:58201-6506
Practice Address - Country:US
Practice Address - Phone:701-314-0103
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-30
Last Update Date:2020-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND1474415171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND1474415Medicaid