Provider Demographics
NPI:1720968142
Name:HUSTAD, NICOLE JEANNE'
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:JEANNE'
Last Name:HUSTAD
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:PO BOX 4435
Mailing Address - Street 2:
Mailing Address - City:EAGLE
Mailing Address - State:CO
Mailing Address - Zip Code:81631-4435
Mailing Address - Country:US
Mailing Address - Phone:402-560-6036
Mailing Address - Fax:
Practice Address - Street 1:400 SOPRIS AVE
Practice Address - Street 2:
Practice Address - City:CARBONDALE
Practice Address - State:CO
Practice Address - Zip Code:81623-2038
Practice Address - Country:US
Practice Address - Phone:970-384-6000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-09-05
Last Update Date:2025-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO390200000X390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program