Provider Demographics
NPI:1982872842
Name:KLEFSTAD JOHNSON, NICOLE
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:KLEFSTAD JOHNSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:227 16TH ST W STE 100
Mailing Address - Street 2:
Mailing Address - City:DICKINSON
Mailing Address - State:ND
Mailing Address - Zip Code:58601-4675
Mailing Address - Country:US
Mailing Address - Phone:701-225-0767
Mailing Address - Fax:701-225-7123
Practice Address - Street 1:979 CENTRAL AVE N
Practice Address - Street 2:
Practice Address - City:VALLEY CITY
Practice Address - State:ND
Practice Address - Zip Code:58072-2149
Practice Address - Country:US
Practice Address - Phone:701-845-8227
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-02-13
Last Update Date:2008-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND809225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist