Provider Demographics
NPI:1376883926
Name:LEONHARDT, NICHOLE RAE
Entity Type:Individual
Prefix:MRS
First Name:NICHOLE
Middle Name:RAE
Last Name:LEONHARDT
Suffix:
Gender:F
Credentials:
Other - Prefix:MS
Other - First Name:NICHOLE
Other - Middle Name:RAE
Other - Last Name:SCHWALENBERG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CMT
Mailing Address - Street 1:803 W ELSIE ST
Mailing Address - Street 2:
Mailing Address - City:APPLETON
Mailing Address - State:WI
Mailing Address - Zip Code:54914-3762
Mailing Address - Country:US
Mailing Address - Phone:920-309-2325
Mailing Address - Fax:
Practice Address - Street 1:350 E ANN ST
Practice Address - Street 2:
Practice Address - City:KAUKAUNA
Practice Address - State:WI
Practice Address - Zip Code:54130-3969
Practice Address - Country:US
Practice Address - Phone:920-462-0912
Practice Address - Fax:920-462-0914
Is Sole Proprietor?:No
Enumeration Date:2013-02-19
Last Update Date:2013-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI11209-146225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist