Provider Demographics
NPI:1881986875
Name:GRIFFIN, NICOLA E (ABOC)
Entity type:Individual
Prefix:
First Name:NICOLA
Middle Name:E
Last Name:GRIFFIN
Suffix:
Gender:F
Credentials:ABOC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1955 GENEVA AVE N
Mailing Address - Street 2:
Mailing Address - City:OAKDALE
Mailing Address - State:MN
Mailing Address - Zip Code:55128-4108
Mailing Address - Country:US
Mailing Address - Phone:612-819-3232
Mailing Address - Fax:
Practice Address - Street 1:1955 GENEVA AVE N
Practice Address - Street 2:
Practice Address - City:OAKDALE
Practice Address - State:MN
Practice Address - Zip Code:55128-4108
Practice Address - Country:US
Practice Address - Phone:612-819-3232
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-05-09
Last Update Date:2012-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN096034156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician