Provider Demographics
NPI:1508033762
Name:WATHKE, NICOLE (PTA)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:WATHKE
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20643 JUNEAU RD
Mailing Address - Street 2:
Mailing Address - City:WILTON
Mailing Address - State:WI
Mailing Address - Zip Code:54670-6127
Mailing Address - Country:US
Mailing Address - Phone:608-372-4695
Mailing Address - Fax:
Practice Address - Street 1:614 S ROCK AVE
Practice Address - Street 2:
Practice Address - City:VIROQUA
Practice Address - State:WI
Practice Address - Zip Code:54665
Practice Address - Country:US
Practice Address - Phone:608-637-2171
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-05-15
Last Update Date:2012-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI729225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant