Provider Demographics
NPI:1346266178
Name:VALK, NICOLE L
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:L
Last Name:VALK
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 1:2656 N 63RD ST
Mailing Address - Street 2:
Mailing Address - City:WAUWATOSA
Mailing Address - State:WI
Mailing Address - Zip Code:53213-1550
Mailing Address - Country:US
Mailing Address - Phone:262-240-9000
Mailing Address - Fax:
Practice Address - Street 1:250 W COVENTRY CT
Practice Address - Street 2:SUITE 204
Practice Address - City:GLENDALE
Practice Address - State:WI
Practice Address - Zip Code:53217-3972
Practice Address - Country:US
Practice Address - Phone:414-228-7900
Practice Address - Fax:414-228-7901
Is Sole Proprietor?:No
Enumeration Date:2006-07-14
Last Update Date:2008-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5064-024225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40307400Medicaid