Provider Demographics
NPI:1336699818
Name:WIEDEKE, NICOLE
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:WIEDEKE
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 1:9041 NW 12TH CT
Mailing Address - Street 2:
Mailing Address - City:PEMBROKE PINES
Mailing Address - State:FL
Mailing Address - Zip Code:33024-4626
Mailing Address - Country:US
Mailing Address - Phone:954-825-9281
Mailing Address - Fax:
Practice Address - Street 1:9041 NW 12TH COURT
Practice Address - Street 2:
Practice Address - City:PEMBROKE PINES
Practice Address - State:FL
Practice Address - Zip Code:33024
Practice Address - Country:US
Practice Address - Phone:954-825-9281
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-10
Last Update Date:2016-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA72749174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist