Provider Demographics
NPI:1215688734
Name:LIND, NICOLE ROSE
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:ROSE
Last Name:LIND
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1413 LAVENDER AVE
Mailing Address - Street 2:
Mailing Address - City:SARTELL
Mailing Address - State:MN
Mailing Address - Zip Code:56377-4830
Mailing Address - Country:US
Mailing Address - Phone:218-204-0827
Mailing Address - Fax:
Practice Address - Street 1:1001 4TH ST SE
Practice Address - Street 2:
Practice Address - City:SAINT CLOUD
Practice Address - State:MN
Practice Address - Zip Code:56304-1297
Practice Address - Country:US
Practice Address - Phone:320-258-0155
Practice Address - Fax:320-258-0152
Is Sole Proprietor?:No
Enumeration Date:2022-01-17
Last Update Date:2022-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN122928183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist