Provider Demographics
NPI:1073237442
Name:DASSOW, NICOLE R (NP)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:R
Last Name:DASSOW
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:700 PARK RIDGE LN
Mailing Address - Street 2:
Mailing Address - City:NORTH FOND DU LAC
Mailing Address - State:WI
Mailing Address - Zip Code:54937-1385
Mailing Address - Country:US
Mailing Address - Phone:920-926-7800
Mailing Address - Fax:920-921-3500
Practice Address - Street 1:700 PARK RIDGE LN
Practice Address - Street 2:
Practice Address - City:NORTH FOND DU LAC
Practice Address - State:WI
Practice Address - Zip Code:54937-1385
Practice Address - Country:US
Practice Address - Phone:920-926-7800
Practice Address - Fax:920-921-3500
Is Sole Proprietor?:No
Enumeration Date:2022-09-29
Last Update Date:2023-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI13161-033363LP0808X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner