Provider Demographics
NPI:1841615770
Name:NYBERG, NICOLE EMILY (NP)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:EMILY
Last Name:NYBERG
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 60447
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-0447
Mailing Address - Country:US
Mailing Address - Phone:910-721-4400
Mailing Address - Fax:910-721-4409
Practice Address - Street 1:20 MEDICAL CAMPUS DR NW STE 205
Practice Address - Street 2:
Practice Address - City:SUPPLY
Practice Address - State:NC
Practice Address - Zip Code:28462-4094
Practice Address - Country:US
Practice Address - Phone:910-721-4400
Practice Address - Fax:910-721-4409
Is Sole Proprietor?:No
Enumeration Date:2014-03-01
Last Update Date:2024-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209.011198363LN0000X, 363LN0005X
VA0024186415363LN0000X
NC5015884363LN0000X, 363L00000X, 363LN0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LN0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerNeonatal
No363LN0005XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerNeonatal, Critical Care