1114589181 NPI number — NICOLETT RAE BRANDT APRN

Table of content: NICOLETT RAE BRANDT APRN (NPI 1114589181)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1114589181 NPI number — NICOLETT RAE BRANDT APRN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BRANDT
Provider First Name:
NICOLETT
Provider Middle Name:
RAE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
APRN
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1114589181
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/01/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1623 5TH AVE SE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ROCHESTER
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55904-5279
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
507-512-0461
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
210 9TH ST SE STE 1
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ROCHESTER
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55904-6400
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
507-288-3443
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/01/2019

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 163W00000X , with the licence number:  2020732 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)