Provider Demographics
NPI:1316393895
Name:EIDE, NICOLE
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:EIDE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3587 S 75TH ST
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53220-1137
Mailing Address - Country:US
Mailing Address - Phone:414-588-2207
Mailing Address - Fax:
Practice Address - Street 1:3415 SHERIDAN RD
Practice Address - Street 2:
Practice Address - City:KENOSHA
Practice Address - State:WI
Practice Address - Zip Code:53140-1924
Practice Address - Country:US
Practice Address - Phone:262-657-6175
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-05-13
Last Update Date:2016-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5859-26225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist