Basic Information
Provider Information | |||||||||
NPI: | 1487717070 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | NICKERSON | ||||||||
FirstName: | AMBER | ||||||||
MiddleName: | MICHELLE | ||||||||
NamePrefix: | MRS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | MS CF SLP | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | BLECKEN | ||||||||
OtherFirstName: | AMBER | ||||||||
OtherMiddleName: | MICHELLE | ||||||||
OtherNamePrefix: | MS. | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 6002 | ||||||||
Address2: |   | ||||||||
City: | GRAND FORKS | ||||||||
State: | ND | ||||||||
PostalCode: | 582066002 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7017805345 | ||||||||
FaxNumber: | 7017801942 | ||||||||
Practice Location | |||||||||
Address1: | 1000 S COLUMBIA RD | ||||||||
Address2: |   | ||||||||
City: | GRAND FORKS | ||||||||
State: | ND | ||||||||
PostalCode: | 582014036 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7017805345 | ||||||||
FaxNumber: | 7017801942 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/18/2006 | ||||||||
LastUpdateDate: | 07/08/2007 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 235Z00000X | 962 | ND | Y |   | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |   | 235Z00000X | 8119 | MN | N |   | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |   |
No ID Information.