Basic Information
| Provider Information | |||||||||
| NPI: | 1679556070 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | NICKEL | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | ANN | ||||||||
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| Credential: | APRN, CNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6565 FRANCE AVE S | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | EDINA | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554352137 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9529202200 | ||||||||
| FaxNumber: | 9529200866 | ||||||||
| Practice Location | |||||||||
| Address1: | 6565 FRANCE AVE S | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | EDINA | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554352137 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9529202200 | ||||||||
| FaxNumber: | 9529200866 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/21/2005 | ||||||||
| LastUpdateDate: | 03/07/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LW0102X | R0522737 | MN | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Women's Health |
ID Information
| ID | Type | State | Issuer | Description | 237318100 | 05 | MN | MEDICAID |