Provider Demographics
NPI:1174006092
Name:ANDERSON, NICOLE ANN
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:ANN
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:ANN
Other - Last Name:ROTTER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:N6280 COUNTY ROAD C
Mailing Address - Street 2:
Mailing Address - City:CECIL
Mailing Address - State:WI
Mailing Address - Zip Code:54111-9344
Mailing Address - Country:US
Mailing Address - Phone:920-639-1274
Mailing Address - Fax:
Practice Address - Street 1:N6280 CTY RD C
Practice Address - Street 2:
Practice Address - City:CECIL
Practice Address - State:WI
Practice Address - Zip Code:54111-9344
Practice Address - Country:US
Practice Address - Phone:920-639-1274
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-07
Last Update Date:2022-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI236237-30163WH0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WH0200XNursing Service ProvidersRegistered NurseHome Health