Provider Demographics
NPI:1811059249
Name:NICKOU, KERRY THOMAS (RNC, FNP)
Entity type:Individual
Prefix:MR
First Name:KERRY
Middle Name:THOMAS
Last Name:NICKOU
Suffix:
Gender:M
Credentials:RNC, FNP
Other - Prefix:
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Other - Middle Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:60 HEART BUTTE CUT OFF
Mailing Address - Street 2:P.O. BOX 209
Mailing Address - City:EAST GLACIER PARK
Mailing Address - State:MT
Mailing Address - Zip Code:59434
Mailing Address - Country:US
Mailing Address - Phone:406-226-9271
Mailing Address - Fax:
Practice Address - Street 1:760 PEIGAN STREET
Practice Address - Street 2:
Practice Address - City:BROWNING
Practice Address - State:MT
Practice Address - Zip Code:59417
Practice Address - Country:US
Practice Address - Phone:406-338-6366
Practice Address - Fax:406-338-6379
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-14
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTRN 19752363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MTP33870Medicare UPIN