Provider Demographics
NPI:1114000213
Name:DEBROUX, NICOLE SUZANNE (DC)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:SUZANNE
Last Name:DEBROUX
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2006 PROGRESS BLVD
Mailing Address - Street 2:
Mailing Address - City:ANTIGO
Mailing Address - State:WI
Mailing Address - Zip Code:54409
Mailing Address - Country:US
Mailing Address - Phone:715-623-5481
Mailing Address - Fax:715-627-0177
Practice Address - Street 1:2006 PROGRESS BLVD
Practice Address - Street 2:
Practice Address - City:ANTIGO
Practice Address - State:WI
Practice Address - Zip Code:54409
Practice Address - Country:US
Practice Address - Phone:715-623-5481
Practice Address - Fax:715-627-0177
Is Sole Proprietor?:No
Enumeration Date:2006-10-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3545012111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI58113OtherSECURITY HEALTH PLAN
U73671Medicare UPIN
35149Medicare ID - Type Unspecified