Provider Demographics
NPI:1366092256
Name:NYQUIST, NICOLE DEBORAH (LMT)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:DEBORAH
Last Name:NYQUIST
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:560 119TH LN NW
Mailing Address - Street 2:
Mailing Address - City:COON RAPIDS
Mailing Address - State:MN
Mailing Address - Zip Code:55448-2218
Mailing Address - Country:US
Mailing Address - Phone:763-458-2938
Mailing Address - Fax:
Practice Address - Street 1:3300 OAKDALE AVE N
Practice Address - Street 2:
Practice Address - City:ROBBINSDALE
Practice Address - State:MN
Practice Address - Zip Code:55422-2926
Practice Address - Country:US
Practice Address - Phone:763-458-2938
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-12
Last Update Date:2019-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist