Provider Demographics
NPI:1386313088
Name:NIBERT, NATALIE GRACE (OD)
Entity type:Individual
Prefix:DR
First Name:NATALIE
Middle Name:GRACE
Last Name:NIBERT
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:111 KELLOGG BLVD E APT 815
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55101-1207
Mailing Address - Country:US
Mailing Address - Phone:316-573-3801
Mailing Address - Fax:
Practice Address - Street 1:13889 RIDGEDALE DR
Practice Address - Street 2:
Practice Address - City:MINNETONKA
Practice Address - State:MN
Practice Address - Zip Code:55305-1768
Practice Address - Country:US
Practice Address - Phone:763-241-1090
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-07
Last Update Date:2021-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN3750152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist