Provider Demographics
NPI:1396176517
Name:SYVERSON, NICOLE
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:SYVERSON
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 1:521 3RD AVE
Mailing Address - Street 2:
Mailing Address - City:REYNOLDS
Mailing Address - State:ND
Mailing Address - Zip Code:58275-4122
Mailing Address - Country:US
Mailing Address - Phone:218-779-9348
Mailing Address - Fax:
Practice Address - Street 1:521 3RD AVE
Practice Address - Street 2:
Practice Address - City:REYNOLD
Practice Address - State:ND
Practice Address - Zip Code:58275
Practice Address - Country:US
Practice Address - Phone:218-779-9348
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-12-13
Last Update Date:2013-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NDL14427164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse