Provider Demographics
NPI:1124615539
Name:VANDERWALKER, NICHOLE NERSETH (RN)
Entity type:Individual
Prefix:MRS
First Name:NICHOLE
Middle Name:NERSETH
Last Name:VANDERWALKER
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2130 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MONTROSE
Mailing Address - State:CO
Mailing Address - Zip Code:81401-3834
Mailing Address - Country:US
Mailing Address - Phone:970-252-3200
Mailing Address - Fax:
Practice Address - Street 1:300 N CASCADE AVE
Practice Address - Street 2:
Practice Address - City:MONTROSE
Practice Address - State:CO
Practice Address - Zip Code:81401-3537
Practice Address - Country:US
Practice Address - Phone:970-252-3203
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-31
Last Update Date:2020-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO0164463163WG0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WG0000XNursing Service ProvidersRegistered NurseGeneral Practice