Provider Demographics
NPI:1134492721
Name:CORK, NICOLE P (BSW)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:P
Last Name:CORK
Suffix:
Gender:F
Credentials:BSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:W12923 5TH ST
Mailing Address - Street 2:
Mailing Address - City:OSSEO
Mailing Address - State:WI
Mailing Address - Zip Code:54758-7496
Mailing Address - Country:US
Mailing Address - Phone:715-533-1164
Mailing Address - Fax:
Practice Address - Street 1:1407 SAINT ANDREW ST STE 100
Practice Address - Street 2:
Practice Address - City:LA CROSSE
Practice Address - State:WI
Practice Address - Zip Code:54603-2378
Practice Address - Country:US
Practice Address - Phone:608-785-3611
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-02-14
Last Update Date:2012-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI8419-120171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator