NPIMap

Individual provider Active NPI

Nicole Lynn Ulrich, D.O.

  • Family Medicine Physician
  • Prior Lake, MN
National Provider Identifier
1093032484
Registry record updated May 22, 2015
On this page

Key facts

NPPES NPI Registry
Primary specialty
Family Medicine PhysicianTaxonomy code 207Q00000X
License
54301 Issued in MN
Practice address
4670 Park Nicollet Ave SE
Prior Lake, MN 55372-4119
Phone
(952) 993-8829
NPI assigned
Apr 26, 2010
Sex
Female
Sole proprietor
Yes

NPPES NPI Registry

Updated by the provider on May 22, 2015

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 2

Specialty (taxonomy)CodeLicenseStatePrimary
Student in an Organized Health Care Education/Training Program 390200000X
Family Medicine Physician 207Q00000X 54301 MN Primary

Addresses

Primary practice location

4670 Park Nicollet Ave SE
Prior Lake, MN 55372-4119

Mailing address

4670 Park Nicollet Ave SE
Prior Lake, MN 55372-4119
Phone (952) 993-8829

Other names 1

  • Nicole Lynn Charboneau Former name

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in MN
Eligible to order & refer
  • Part B services
  • Medical equipment
  • Home health
  • Power mobility devices
  • Hospice
Green means eligible to order or refer.

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
I20110921000250 MN Practitioner - Family PracticePractitioner - Osteopathic Manipulative Medicine 3779754833 Reassigns benefits to 1 organization

Care Compare profile

Medicare Care Compare
Specialty
Family PracticeAlso: Osteopathic Manipulative Medicine
Education
Other, 2010
Medicare assignment
Accepts the Medicare-approved amount as payment in full
Telehealth
Offers telehealth services
Group practices
Park Nicollet ClinicGroup PAC ID 7911819438, 1,778 clinicians

Practice addresses (Care Compare)

4670 Park Nicollet Ave SE
Prior Lake, MN 55372-4119
Phone (952) 993-7750

Hospital & facility affiliations

Procedures performed for Medicare patients

ProcedureNumber of procedures
Removal of skin lesions1-10
Removal or shaving of skin growth1-10

National Provider Directory

National Provider Directory
Medicare enrollment (NPD)
Enrolled
Credentials
Doctor of Osteopathy

Practice roles

OrganizationSpecialtyStatusNew patients
Park Nicollet Clinic Family Medicine CurrentSince Jul 10, 2017 Accepting new patients
Park Nicollet Clinic Family Medicine CurrentSince Jul 10, 2017 Accepting new patients

Locations

5320 Hyland Greens Dr
Minneapolis, MN 55437
Phone (952) 993-2400

4670 Park Nicollet Ave SE
Prior Lake, MN 55372
Phone (952) 993-7750

Interoperability endpoints

  • Direct secure messaging: nulrich156776@direct.healthpartners.com

Organizations & group practices 2

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.

Hospital & facility affiliations 7

Hospitals and other facilities this clinician is affiliated with according to Medicare Care Compare.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1272240000000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1432252800000",
    "number": "1093032484",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "4670 PARK NICOLLET AVE SE",
            "city": "PRIOR LAKE",
            "state": "MN",
            "postal_code": "553724119",
            "telephone_number": "952-993-8829"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "4670 PARK NICOLLET AVE SE",
            "city": "PRIOR LAKE",
            "state": "MN",
            "postal_code": "553724119",
            "telephone_number": "952-993-8829"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "ULRICH",
        "first_name": "NICOLE",
        "middle_name": "LYNN",
        "credential": "D.O.",
        "sole_proprietor": "YES",
        "sex": "F",
        "enumeration_date": "2010-04-26",
        "last_updated": "2015-05-22",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "390200000X",
            "taxonomy_group": "",
            "desc": "Student in an Organized Health Care Education/Training Program",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "207Q00000X",
            "taxonomy_group": "",
            "desc": "Family Medicine",
            "state": "MN",
            "license": "54301",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "first_name": "NICOLE",
            "last_name": "CHARBONEAU",
            "middle_name": "LYNN",
            "code": "1",
            "type": "Former Name"
        }
    ]
}

Other providers in Prior Lake, MN

Sources for this page

Verify at the official NPI Registry.