Provider Demographics
NPI:1487425039
Name:WILSON, NICHOLE CAROL (RN)
Entity type:Individual
Prefix:
First Name:NICHOLE
Middle Name:CAROL
Last Name:WILSON
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:PO BOX 1011
Mailing Address - Street 2:
Mailing Address - City:MANDAN
Mailing Address - State:ND
Mailing Address - Zip Code:58554-7011
Mailing Address - Country:US
Mailing Address - Phone:701-426-0464
Mailing Address - Fax:
Practice Address - Street 1:420 E MAIN AVE APT 610
Practice Address - Street 2:
Practice Address - City:BISMARCK
Practice Address - State:ND
Practice Address - Zip Code:58501-4068
Practice Address - Country:US
Practice Address - Phone:701-426-0464
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-12
Last Update Date:2024-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
374U00000X, 3747P1801X
NDR54683163WH0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant
No374U00000XNursing Service Related ProvidersHome Health Aide
No163WH0200XNursing Service ProvidersRegistered NurseHome Health