Provider Demographics
NPI:1164772877
Name:MARTY, NICHOLE ANN (FNP-BC)
Entity Type:Individual
Prefix:
First Name:NICHOLE
Middle Name:ANN
Last Name:MARTY
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:NICHOLE
Other - Middle Name:ANN
Other - Last Name:PADJEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:719 W HAMILTON AVE STE B
Mailing Address - Street 2:
Mailing Address - City:EAU CLAIRE
Mailing Address - State:WI
Mailing Address - Zip Code:54701-6970
Mailing Address - Country:US
Mailing Address - Phone:715-552-9784
Mailing Address - Fax:
Practice Address - Street 1:3213 STEIN BLVD
Practice Address - Street 2:
Practice Address - City:EAU CLAIRE
Practice Address - State:WI
Practice Address - Zip Code:54701-6946
Practice Address - Country:US
Practice Address - Phone:715-830-0732
Practice Address - Fax:715-830-5487
Is Sole Proprietor?:No
Enumeration Date:2012-09-11
Last Update Date:2021-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5106-33363LF0000X
WI166788-30163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse