Provider Demographics
NPI:1568985257
Name:BUATALA, NICOLE SZUDY (RN, MSN, FNP, PMHNP)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:SZUDY
Last Name:BUATALA
Suffix:
Gender:F
Credentials:RN, MSN, FNP, PMHNP
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:MARIE
Other - Last Name:SZUDY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2103 COUNTY ROAD D E STE B
Mailing Address - Street 2:
Mailing Address - City:MAPLEWOOD
Mailing Address - State:MN
Mailing Address - Zip Code:55109-5358
Mailing Address - Country:US
Mailing Address - Phone:651-748-5019
Mailing Address - Fax:651-383-4529
Practice Address - Street 1:2103 COUNTY ROAD D E STE B
Practice Address - Street 2:
Practice Address - City:MAPLEWOOD
Practice Address - State:MN
Practice Address - Zip Code:55109-5358
Practice Address - Country:US
Practice Address - Phone:651-748-5019
Practice Address - Fax:651-383-4529
Is Sole Proprietor?:No
Enumeration Date:2017-07-25
Last Update Date:2025-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN5299363LF0000X, 363LP0808X
WI9918363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily