Provider Demographics
NPI:1316590417
Name:SLETTEN, NICOLE RAE
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:RAE
Last Name:SLETTEN
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:N9581 FENSKE ROAD
Mailing Address - Street 2:
Mailing Address - City:DALTON
Mailing Address - State:WI
Mailing Address - Zip Code:53926
Mailing Address - Country:US
Mailing Address - Phone:608-408-8692
Mailing Address - Fax:
Practice Address - Street 1:N9581 FENSKE ROAD
Practice Address - Street 2:
Practice Address - City:DALTON
Practice Address - State:WI
Practice Address - Zip Code:53926
Practice Address - Country:US
Practice Address - Phone:608-408-8692
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-18
Last Update Date:2021-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4718224Z00000X
WI6947-26225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
No224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant