Individual
MRS. NICOLE THERESE MANECKE
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
PA
Contact information
Practice address
13359 ISLE DR, SUITE 3, BAXTER, MN 56425-2222
(218) 454-7546
(218) 454-3062
Mailing address
13359 ISLE DR, SUITE 3, BAXTER, MN 56425-2222
(218) 454-7546
Taxonomy
Speciality
Code
Description
License number
State
363AM0700X
Medical Physician Assistant
Primary
085-001851
IL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
1720269426
DERMATOLOGY PROFESSIONALS, PA TYPE 2 NPI
MN
Enumeration date
09/28/2006
Last updated
07/09/2008
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