NPIMap

Organization Active NPI

Northern Lights Health LLC

  • Primary Care Nurse Practitioner
  • Waconia, MN
National Provider Identifier
1316581440
Registry record updated Dec 22, 2019
On this page

Key facts

NPPES NPI Registry
Primary specialty
Primary Care Nurse PractitionerTaxonomy code 363LP2300X
Legal business name
NORTHERN LIGHTS HEALTH LLC
Practice address
212 W Lake St
Waconia, MN 55387-1014
Phone
(920) 217-9035
NPI assigned
Oct 31, 2019
Last updated
Dec 22, 2019By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Dec 22, 2019

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

Authorized official

Name
Nicole M Siddons, FNP-CNPI 1467803403
Title
Co-Founder
Phone
(920) 217-9035

Authorized official NPPES reports the official by name only. The link goes to the one practitioner connected to this organization with that name.

Specialties & licenses 5

Specialty (taxonomy)CodeLicenseStatePrimary
Acute Care Nurse PractitionerGroup: 193200000X MULTI-SPECIALTY GROUP 363LA2100X
Adult Health Nurse PractitionerGroup: 193200000X MULTI-SPECIALTY GROUP 363LA2200X
Family Nurse PractitionerGroup: 193200000X MULTI-SPECIALTY GROUP 363LF0000X
Gerontology Nurse PractitionerGroup: 193200000X MULTI-SPECIALTY GROUP 363LG0600X
Primary Care Nurse PractitionerGroup: 193200000X MULTI-SPECIALTY GROUP 363LP2300X Primary

Addresses

Primary practice location

212 W Lake St
Waconia, MN 55387-1014

Mailing address

212 W Lake St
Waconia, MN 55387-1014
Phone (920) 217-9035

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in MN, WI2 enrollments

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20191125001002 MN Part B Supplier - Clinic/Group Practice 6305278797 Receives reassigned benefits from 18 practitioners
Practice locations: Waconia, MN
O20240620000228 WI Part B Supplier - Clinic/Group Practice 6305278797 Receives reassigned benefits from 7 practitioners
Practice locations: Saint Croix Falls, WI

Laboratory certificates & supplier records

Derived by NPIMap

These CMS records do not include an NPI. They are shown because their name and street address match this provider’s.

CLIA laboratory certificates

CLIA numberLaboratoryCertificateExpires
24D2199463Northern Lights Health212 W Lake Street, Waconia, MN 55387Certificate of waiverNov 8, 2026

National Provider Directory

National Provider Directory

Locations

750 E Louisiana St
Saint Croix Falls, WI 54024
Phone (715) 483-2713

Practitioners & affiliated clinicians

Practitioners 19

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

View all 19

NPI Registry JSON

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

{
    "created_epoch": "1572480000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1576972800000",
    "number": "1316581440",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "212 W LAKE ST",
            "city": "WACONIA",
            "state": "MN",
            "postal_code": "553871014",
            "telephone_number": "920-217-9035"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "212 W LAKE ST",
            "city": "WACONIA",
            "state": "MN",
            "postal_code": "553871014",
            "telephone_number": "920-217-9035"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "NORTHERN LIGHTS HEALTH LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2019-10-31",
        "last_updated": "2019-12-22",
        "certification_date": "2019-12-22",
        "status": "A",
        "authorized_official_last_name": "SIDDONS",
        "authorized_official_first_name": "NICOLE",
        "authorized_official_middle_name": "M",
        "authorized_official_title_or_position": "CO-FOUNDER",
        "authorized_official_telephone_number": "920-217-9035",
        "authorized_official_credential": "FNP-C"
    },
    "taxonomies": [
        {
            "code": "363LA2100X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Nurse Practitioner, Acute Care",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "363LA2200X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Nurse Practitioner, Adult Health",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "363LF0000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Nurse Practitioner, Family",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "363LG0600X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Nurse Practitioner, Gerontology",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "363LP2300X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Nurse Practitioner, Primary Care",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Waconia, MN

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Dec 22, 2019; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.