Provider Demographics
NPI:1497851141
Name:NICHOLAS, TAMMY KAY (PT)
Entity Type:Individual
Prefix:
First Name:TAMMY
Middle Name:KAY
Last Name:NICHOLAS
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:TAMMY
Other - Middle Name:KAY
Other - Last Name:SEEGERS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:13825 W BURLEIGH RD
Mailing Address - Street 2:
Mailing Address - City:BROOKFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:53005-3058
Mailing Address - Country:US
Mailing Address - Phone:262-754-3450
Mailing Address - Fax:262-754-3451
Practice Address - Street 1:600 N BARKER RD
Practice Address - Street 2:
Practice Address - City:BROOKFIELD
Practice Address - State:WI
Practice Address - Zip Code:53045-5919
Practice Address - Country:US
Practice Address - Phone:262-754-3461
Practice Address - Fax:262-797-0730
Is Sole Proprietor?:No
Enumeration Date:2006-09-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI6429-024225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI36117400Medicaid
WI1891711008Medicare ID - Type UnspecifiedSMART CLINIC GROUP NPI