Provider Demographics
NPI:1942322565
Name:FITZGERALD, NICOLE ANNE (DC)
Entity type:Individual
Prefix:DR
First Name:NICOLE
Middle Name:ANNE
Last Name:FITZGERALD
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4520 DOUGLAS AVE
Mailing Address - Street 2:
Mailing Address - City:DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50310-2710
Mailing Address - Country:US
Mailing Address - Phone:515-276-2263
Mailing Address - Fax:515-251-2969
Practice Address - Street 1:4520 DOUGLAS AVE
Practice Address - Street 2:
Practice Address - City:DES MOINES
Practice Address - State:IA
Practice Address - Zip Code:50310-2710
Practice Address - Country:US
Practice Address - Phone:515-276-2263
Practice Address - Fax:515-251-2969
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA06770111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0466979Medicaid
IA38636OtherWELLMARK BCBS PROVIDER ID
IA38636OtherWELLMARK BCBS PROVIDER ID
IA0466979Medicaid