Provider Demographics
NPI:1699127340
Name:LANGE, NICOLE (LAC MAOM)
Entity type:Individual
Prefix:MS
First Name:NICOLE
Middle Name:
Last Name:LANGE
Suffix:
Gender:F
Credentials:LAC MAOM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3101 35TH AVE S
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55406-2113
Mailing Address - Country:US
Mailing Address - Phone:612-423-9986
Mailing Address - Fax:
Practice Address - Street 1:2615 PARK AVE
Practice Address - Street 2:SUITE B4
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55407-1035
Practice Address - Country:US
Practice Address - Phone:612-423-9986
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-06
Last Update Date:2016-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1377171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist