Provider Demographics
NPI:1346975356
Name:WHEELER, NICOLE ASHLEY
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:ASHLEY
Last Name:WHEELER
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 1:2741 W LAYTON AVE STE 106
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53221-2600
Mailing Address - Country:US
Mailing Address - Phone:414-286-7420
Mailing Address - Fax:
Practice Address - Street 1:17475 DUGDALE DR
Practice Address - Street 2:
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46635-1545
Practice Address - Country:US
Practice Address - Phone:574-247-7500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-22
Last Update Date:2023-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71023836A363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN71012836AOtherNURSE PRACTITIONER