Provider Demographics
NPI:1164858023
Name:CONKLIN, NICOLE ANN (PHARMD)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:ANN
Last Name:CONKLIN
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1614 PERNIN ST
Mailing Address - Street 2:
Mailing Address - City:MARINETTE
Mailing Address - State:WI
Mailing Address - Zip Code:54143-3433
Mailing Address - Country:US
Mailing Address - Phone:231-349-2912
Mailing Address - Fax:
Practice Address - Street 1:2741 ROOSEVELT RD
Practice Address - Street 2:
Practice Address - City:MARINETTE
Practice Address - State:WI
Practice Address - Zip Code:54143-3833
Practice Address - Country:US
Practice Address - Phone:715-735-0325
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-09-23
Last Update Date:2013-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI15134-40183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist