NPIMap

Organization Active NPI

Waterside Healthcare & Wellness, LLC

  • Family Nurse Practitioner
  • Waconia, MN
National Provider Identifier
1780223743
Registry record updated Dec 22, 2019
On this page

Key facts

NPPES NPI Registry
Primary specialty
Family Nurse PractitionerTaxonomy code 363LF0000X
Legal business name
WATERSIDE HEALTHCARE & WELLNESS, LLC
Practice address
212 W Lake St
Waconia, MN 55387-1014
Phone
(920) 217-9035
NPI assigned
Dec 22, 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
Owner of Entity
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 1

Specialty (taxonomy)CodeLicenseStatePrimary
Family Nurse Practitioner 363LF0000X 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

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
24D2181217Waterside Healthcare & Wellness LLC212 W Lake St, Waconia, MN 55387Certificate of waiverMar 29, 2028

National Provider Directory

National Provider Directory

Practitioners & affiliated clinicians

Practitioners 15

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 15

NPI Registry JSON

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

{
    "created_epoch": "1576972800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1576972800000",
    "number": "1780223743",
    "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": "WATERSIDE HEALTHCARE & WELLNESS, LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2019-12-22",
        "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": "OWNER OF ENTITY",
        "authorized_official_telephone_number": "920-217-9035",
        "authorized_official_credential": "FNP-C"
    },
    "taxonomies": [
        {
            "code": "363LF0000X",
            "taxonomy_group": "",
            "desc": "Nurse Practitioner, Family",
            "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 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.