Provider Demographics
NPI:1295257400
Name:MULLIS, NICOLE L (FNP-C)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:L
Last Name:MULLIS
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:
Other - Last Name:MEARS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1450 10TH ST S
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58103-4121
Mailing Address - Country:US
Mailing Address - Phone:701-318-2135
Mailing Address - Fax:
Practice Address - Street 1:301 NORTHERN PACIFIC AVE N
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58102-4835
Practice Address - Country:US
Practice Address - Phone:701-271-3344
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-07-10
Last Update Date:2021-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NDR30211363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily