Basic Information
Provider Information | |||||||||
NPI: | 1457393704 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | LINGEN | ||||||||
FirstName: | NICOLE | ||||||||
MiddleName: | A | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | DC | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 5074 | ||||||||
Address2: |   | ||||||||
City: | SIOUX FALLS | ||||||||
State: | SD | ||||||||
PostalCode: | 571175074 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6053286585 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 3001 SANFORD PKWY | ||||||||
Address2: |   | ||||||||
City: | THIEF RIVER FALLS | ||||||||
State: | MN | ||||||||
PostalCode: | 567012700 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2186832725 | ||||||||
FaxNumber: | 2186832595 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/12/2006 | ||||||||
LastUpdateDate: | 08/08/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 08/08/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171100000X | 586 | MN | N |   | Other Service Providers | Acupuncturist |   | 111N00000X | DC4073 | MN | Y |   | Chiropractic Providers | Chiropractor |   |
ID Information
ID | Type | State | Issuer | Description | HP37803 | 01 | MN | HEALTHPARTNERS # | OTHER | 21311 | 01 | MN | NDBS # | OTHER | 395443900 | 05 | MN |   | MEDICAID | DA9020784 | 01 | MN | PREFERRED ONE # | OTHER | 1577854 | 01 | MN | AMERICA'S PPO/ARAZ # | OTHER | 620054 | 01 | MN | MEDICA # | OTHER | 50G09LI | 01 | MN | MNBS # | OTHER |