Basic Information
| Provider Information | |||||||||
| NPI: | 1962917799 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WALKER | ||||||||
| FirstName: | NICOLE | ||||||||
| MiddleName: | KRISTINE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | APRN, CNP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | BUSCH | ||||||||
| OtherFirstName: | NICOLE | ||||||||
| OtherMiddleName: | |||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 614 DILLON AVE N | ||||||||
| Address2: | |||||||||
| City: | MONTROSE | ||||||||
| State: | MN | ||||||||
| PostalCode: | 553634522 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9528078436 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 300 LAKE DR E | ||||||||
| Address2: | |||||||||
| City: | CHANHASSEN | ||||||||
| State: | MN | ||||||||
| PostalCode: | 553179302 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9529934300 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/01/2017 | ||||||||
| LastUpdateDate: | 10/21/2020 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 10/21/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | R169334-8 | MN | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 390200000X | MN | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 363L00000X | 5684 | MN | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
No ID Information.