Provider Demographics
NPI:1164863429
Name:HERZOG, NICOLE S (DPT)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:S
Last Name:HERZOG
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3237 VOYAGER DR
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54311-8349
Mailing Address - Country:US
Mailing Address - Phone:920-468-8288
Mailing Address - Fax:
Practice Address - Street 1:3237 VOYAGER DR
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54311-8349
Practice Address - Country:US
Practice Address - Phone:920-468-8288
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-07-15
Last Update Date:2021-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI12336225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist