Provider Demographics
NPI:1174507933
Name:NICHOLS, COLLEEN MARY (MD)
Entity Type:Individual
Prefix:
First Name:COLLEEN
Middle Name:MARY
Last Name:NICHOLS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:COLLEEN
Other - Middle Name:MARY
Other - Last Name:LAFFEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2801 W KINNICKINNIC RIVER PKWY
Mailing Address - Street 2:SUITE 730
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53215-3669
Mailing Address - Country:US
Mailing Address - Phone:414-649-7202
Mailing Address - Fax:414-649-5158
Practice Address - Street 1:2801 W KINNICKINNIC RIVER PKWY
Practice Address - Street 2:SUITE 730
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53215-3669
Practice Address - Country:US
Practice Address - Phone:414-649-7202
Practice Address - Fax:414-649-5158
Is Sole Proprietor?:No
Enumeration Date:2005-12-05
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI34547-020207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI32136100Medicaid
WIRAILROAD MEDICAREOther110232521
WI34547-020OtherLICENSE
WIBN3798230OtherDEA
WIBN3798230OtherDEA