Provider Demographics
NPI:1528035219
Name:HENTHORN, NIKOLE (NP)
Entity Type:Individual
Prefix:
First Name:NIKOLE
Middle Name:
Last Name:HENTHORN
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2801 W KINNICKINNIC RIVER PKWY STE 1080
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53215-3689
Mailing Address - Country:US
Mailing Address - Phone:414-908-6615
Mailing Address - Fax:414-385-2980
Practice Address - Street 1:2801 W KINNICKINNIC RIVER PKWY STE 1080
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53215-3689
Practice Address - Country:US
Practice Address - Phone:414-908-6615
Practice Address - Fax:414-385-2980
Is Sole Proprietor?:No
Enumeration Date:2006-03-02
Last Update Date:2020-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1809033363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
WIP23599Medicare UPIN