Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 124Q00000X | Dental Hygienist | H5092 | MN |
NPI | 1023348869 |
---|---|
Provider Name | Sondra Nickolson |
First Address | Minneapolis, MN 55413-2164 |
Second Address | Minneapolis, MN 55413-2164 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 29/12/2009 |
Last Update Date | 29/12/2009 |