Provider Demographics
NPI:1720701709
Name:WYGANOWSKI, NICOLE K (RN, PHN, LSN)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:K
Last Name:WYGANOWSKI
Suffix:
Gender:F
Credentials:RN, PHN, LSN
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:K
Other - Last Name:HEIDINGER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN, PHN
Mailing Address - Street 1:30127 105TH ST
Mailing Address - Street 2:
Mailing Address - City:PRINCETON
Mailing Address - State:MN
Mailing Address - Zip Code:55371-6170
Mailing Address - Country:US
Mailing Address - Phone:612-419-0211
Mailing Address - Fax:
Practice Address - Street 1:706 1ST ST
Practice Address - Street 2:
Practice Address - City:PRINCETON
Practice Address - State:MN
Practice Address - Zip Code:55371-1502
Practice Address - Country:US
Practice Address - Phone:763-389-6195
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-23
Last Update Date:2022-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN17656163WC1500X
MN502858163WS0200X, 163W00000X, 163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No163WC1500XNursing Service ProvidersRegistered NurseCommunity Health
No163WS0200XNursing Service ProvidersRegistered NurseSchool