Provider Demographics
NPI:1528150661
Name:MEDINA, NICOLLE L (ARNP)
Entity type:Individual
Prefix:
First Name:NICOLLE
Middle Name:L
Last Name:MEDINA
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:NICOLLE
Other - Middle Name:L
Other - Last Name:AMOS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:ARNP-C
Mailing Address - Street 1:50 N EISENHOWER AVE
Mailing Address - Street 2:
Mailing Address - City:MASON CITY
Mailing Address - State:IA
Mailing Address - Zip Code:50401-7340
Mailing Address - Country:US
Mailing Address - Phone:641-423-5479
Mailing Address - Fax:641-423-6102
Practice Address - Street 1:50 N EISENHOWER AVE
Practice Address - Street 2:
Practice Address - City:MASON CITY
Practice Address - State:IA
Practice Address - Zip Code:50401-7340
Practice Address - Country:US
Practice Address - Phone:641-423-5479
Practice Address - Fax:641-423-6102
Is Sole Proprietor?:No
Enumeration Date:2006-09-28
Last Update Date:2021-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAG166072363LP0808X
IAA099623363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA00439OtherWELLMARK
IA0481150Medicaid
IAI16387Medicare PIN