Provider Demographics
NPI:1669124756
Name:SMITH, NICOLE A (FNP)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:A
Last Name:SMITH
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:A
Other - Last Name:O'DELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:FNP
Mailing Address - Street 1:3500 AMERICAN BLVD W STE 300
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:MN
Mailing Address - Zip Code:55431-4442
Mailing Address - Country:US
Mailing Address - Phone:952-512-5600
Mailing Address - Fax:
Practice Address - Street 1:1804 7TH ST W STE 200
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55116-2300
Practice Address - Country:US
Practice Address - Phone:651-227-7806
Practice Address - Fax:651-256-6710
Is Sole Proprietor?:No
Enumeration Date:2022-01-20
Last Update Date:2024-10-08
Deactivation Date:2022-09-24
Deactivation Code:
Reactivation Date:2022-10-05
Provider Licenses
StateLicense IDTaxonomies
MN243890-0163W00000X
MN9561363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered Nurse