Provider Demographics
NPI:1437728037
Name:FAESSEL, NICOLE MARIE (APRN)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:MARIE
Last Name:FAESSEL
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:MARIE
Other - Last Name:DAVIS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PMHNP-BC, PMH-C
Mailing Address - Street 1:355 CHASE WAY APT B
Mailing Address - Street 2:
Mailing Address - City:BOZEMAN
Mailing Address - State:MT
Mailing Address - Zip Code:59718-5473
Mailing Address - Country:US
Mailing Address - Phone:406-201-5937
Mailing Address - Fax:888-829-4791
Practice Address - Street 1:355 CHASE WAY APT B
Practice Address - Street 2:
Practice Address - City:BOZEMAN
Practice Address - State:MT
Practice Address - Zip Code:59718-5473
Practice Address - Country:US
Practice Address - Phone:406-201-5937
Practice Address - Fax:888-829-4791
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-18
Last Update Date:2025-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID70357363LP0808X
AZ267058363LP0808X
FLTPAN1125363LP0808X
MTNUR-APRN-LIC-176359363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT100149711Medicaid