Provider Demographics
NPI:1487717070
Name:NICKERSON, AMBER MICHELLE (MS CF SLP)
Entity type:Individual
Prefix:MRS
First Name:AMBER
Middle Name:MICHELLE
Last Name:NICKERSON
Suffix:
Gender:F
Credentials:MS CF SLP
Other - Prefix:MS
Other - First Name:AMBER
Other - Middle Name:MICHELLE
Other - Last Name:BLECKEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 6002
Mailing Address - Street 2:
Mailing Address - City:GRAND FORKS
Mailing Address - State:ND
Mailing Address - Zip Code:58206-6002
Mailing Address - Country:US
Mailing Address - Phone:701-780-5345
Mailing Address - Fax:701-780-1942
Practice Address - Street 1:1000 S COLUMBIA RD
Practice Address - Street 2:
Practice Address - City:GRAND FORKS
Practice Address - State:ND
Practice Address - Zip Code:58201-4036
Practice Address - Country:US
Practice Address - Phone:701-780-5345
Practice Address - Fax:701-780-1942
Is Sole Proprietor?:No
Enumeration Date:2006-12-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND962235Z00000X
MN8119235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist