Provider Demographics
NPI:1225187610
Name:WOLFF, NICKEY LOUIS (LAT)
Entity Type:Individual
Prefix:
First Name:NICKEY
Middle Name:LOUIS
Last Name:WOLFF
Suffix:
Gender:M
Credentials:LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2757 N 74TH ST
Mailing Address - Street 2:
Mailing Address - City:WAUWATOSA
Mailing Address - State:WI
Mailing Address - Zip Code:53210-1009
Mailing Address - Country:US
Mailing Address - Phone:414-774-2658
Mailing Address - Fax:
Practice Address - Street 1:N63W23075 STATE HIGHWAY 74
Practice Address - Street 2:
Practice Address - City:SUSSEX
Practice Address - State:WI
Practice Address - Zip Code:53089-2876
Practice Address - Country:US
Practice Address - Phone:414-566-4586
Practice Address - Fax:414-566-4640
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI95-0392255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI95-039OtherSTATE LICENSE