Provider Demographics
NPI:1902117401
Name:HENRIKSEN, NICOLE (OD)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:HENRIKSEN
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22625 293RD AVE
Mailing Address - Street 2:
Mailing Address - City:VIVIAN
Mailing Address - State:SD
Mailing Address - Zip Code:57576-5000
Mailing Address - Country:US
Mailing Address - Phone:605-280-1349
Mailing Address - Fax:
Practice Address - Street 1:534 N LAST CHANCE GULCH
Practice Address - Street 2:
Practice Address - City:HELENA
Practice Address - State:MT
Practice Address - Zip Code:59601-3303
Practice Address - Country:US
Practice Address - Phone:406-442-6814
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-30
Last Update Date:2010-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT819152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist