Provider Demographics
NPI:1902489339
Name:ANDERSON, NICOLE (APRN, CNP)
Entity Type:Individual
Prefix:MS
First Name:NICOLE
Middle Name:
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:APRN, CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1210 OAKEY CT
Mailing Address - Street 2:
Mailing Address - City:OSCEOLA
Mailing Address - State:WI
Mailing Address - Zip Code:54020-4359
Mailing Address - Country:US
Mailing Address - Phone:651-206-2163
Mailing Address - Fax:
Practice Address - Street 1:1715 TOWER DR W STE 100
Practice Address - Street 2:
Practice Address - City:STILLWATER
Practice Address - State:MN
Practice Address - Zip Code:55082-7609
Practice Address - Country:US
Practice Address - Phone:651-390-5001
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-03
Last Update Date:2021-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN8178363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health