Basic Information
| Provider Information | |||||||||
| NPI: | 1336499904 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PELACH | ||||||||
| FirstName: | NICOLE | ||||||||
| MiddleName: | RAE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | N.P. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | TABATT | ||||||||
| OtherFirstName: | NICOLE | ||||||||
| OtherMiddleName: | RAE | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 720 WASHINGTON AVE SE STE 300 | ||||||||
| Address2: | |||||||||
| City: | MINNEAPOLIS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554142904 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6126727422 | ||||||||
| FaxNumber: | 6128840907 | ||||||||
| Practice Location | |||||||||
| Address1: | 2200 NW 26TH ST | ||||||||
| Address2: | |||||||||
| City: | OWATONNA | ||||||||
| State: | MN | ||||||||
| PostalCode: | 550605503 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5074511120 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/11/2012 | ||||||||
| LastUpdateDate: | 02/11/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 02/11/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | R 130266-8 | MN | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363LF0000X | 1207 | MN | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.