Provider Demographics
NPI:1053667667
Name:SMITH, NICOLE STEPHANIE (AUD, CCC-A)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:STEPHANIE
Last Name:SMITH
Suffix:
Gender:F
Credentials:AUD, CCC-A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2215 E CLAIREMONT AVE
Mailing Address - Street 2:SUITE 2
Mailing Address - City:EAU CLAIRE
Mailing Address - State:WI
Mailing Address - Zip Code:54701-4772
Mailing Address - Country:US
Mailing Address - Phone:715-831-0289
Mailing Address - Fax:715-831-4722
Practice Address - Street 1:2215 E CLAIREMONT AVE
Practice Address - Street 2:SUITE 2
Practice Address - City:EAU CLAIRE
Practice Address - State:WI
Practice Address - Zip Code:54701-4772
Practice Address - Country:US
Practice Address - Phone:715-831-0289
Practice Address - Fax:715-831-4722
Is Sole Proprietor?:No
Enumeration Date:2012-08-01
Last Update Date:2017-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI577-156231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1445015Medicare PIN