Provider Demographics
NPI:1205272481
Name:DISHONG, NICOLE M (CNM)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:M
Last Name:DISHONG
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10900 WAYZATA BLVD STE 640
Mailing Address - Street 2:
Mailing Address - City:MINNETONKA
Mailing Address - State:MN
Mailing Address - Zip Code:55305-5602
Mailing Address - Country:US
Mailing Address - Phone:561-208-5734
Mailing Address - Fax:561-208-5734
Practice Address - Street 1:3625 W 65TH ST STE 100
Practice Address - Street 2:
Practice Address - City:EDINA
Practice Address - State:MN
Practice Address - Zip Code:55435-2147
Practice Address - Country:US
Practice Address - Phone:952-920-7001
Practice Address - Fax:952-920-2245
Is Sole Proprietor?:No
Enumeration Date:2013-05-15
Last Update Date:2022-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMR44853163W00000X
NMCNM647176B00000X
MN304367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
No163W00000XNursing Service ProvidersRegistered Nurse
No176B00000XOther Service ProvidersMidwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNH400317380OtherMEDICARE
NM287973YR41Medicare PIN