Provider Demographics
NPI:1972964849
Name:BURKETTE IKEBATA, NICOLE S (MD, MPH)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:S
Last Name:BURKETTE IKEBATA
Suffix:
Gender:F
Credentials:MD, MPH
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:
Other - Last Name:IKEBATA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:2355 HIGHWAY 36 W STE 400
Mailing Address - Street 2:
Mailing Address - City:ROSEVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:55113-3905
Mailing Address - Country:US
Mailing Address - Phone:651-243-8113
Mailing Address - Fax:931-202-8451
Practice Address - Street 1:2355 HIGHWAY 36 W STE 400
Practice Address - Street 2:
Practice Address - City:ROSEVILLE
Practice Address - State:MN
Practice Address - Zip Code:55113-3905
Practice Address - Country:US
Practice Address - Phone:651-243-8113
Practice Address - Fax:931-202-8451
Is Sole Proprietor?:No
Enumeration Date:2016-03-18
Last Update Date:2025-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN663842084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry