Provider Demographics
NPI:1386202448
Name:WENTZIEN, NICOLE M (DPT)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:M
Last Name:WENTZIEN
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:M
Other - Last Name:POIRIER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DPT
Mailing Address - Street 1:3200 E RACINE ST
Mailing Address - Street 2:
Mailing Address - City:JANESVILLE
Mailing Address - State:WI
Mailing Address - Zip Code:53546-2343
Mailing Address - Country:US
Mailing Address - Phone:608-371-8000
Mailing Address - Fax:608-371-8935
Practice Address - Street 1:3200 E RACINE ST
Practice Address - Street 2:
Practice Address - City:JANESVILLE
Practice Address - State:WI
Practice Address - Zip Code:53546-2343
Practice Address - Country:US
Practice Address - Phone:608-371-8000
Practice Address - Fax:608-371-8935
Is Sole Proprietor?:No
Enumeration Date:2019-06-04
Last Update Date:2021-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI14661-24225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist