Provider Demographics
NPI:1326456815
Name:REZACHEK, NICOLE (PTA)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:REZACHEK
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:N27W5707 LINCOLN BLVD
Mailing Address - Street 2:
Mailing Address - City:CEDARBURG
Mailing Address - State:WI
Mailing Address - Zip Code:53012-2852
Mailing Address - Country:US
Mailing Address - Phone:262-376-7676
Mailing Address - Fax:262-376-5208
Practice Address - Street 1:N27W5707 LINCOLN BLVD
Practice Address - Street 2:
Practice Address - City:CEDARBURG
Practice Address - State:WI
Practice Address - Zip Code:53012-2852
Practice Address - Country:US
Practice Address - Phone:262-376-7676
Practice Address - Fax:262-376-5208
Is Sole Proprietor?:No
Enumeration Date:2014-07-28
Last Update Date:2014-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2197-19225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WIPENDING APPLICATIONMedicaid