Provider Demographics
NPI:1558729921
Name:STRUCK, NICOLE
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:STRUCK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8911 N PORT WASHINGTON RD
Mailing Address - Street 2:
Mailing Address - City:BAYSIDE
Mailing Address - State:WI
Mailing Address - Zip Code:53217-1634
Mailing Address - Country:US
Mailing Address - Phone:414-351-5794
Mailing Address - Fax:414-351-2770
Practice Address - Street 1:8911 N PORT WASHINGTON RD
Practice Address - Street 2:
Practice Address - City:BAYSIDE
Practice Address - State:WI
Practice Address - Zip Code:53217-1634
Practice Address - Country:US
Practice Address - Phone:414-351-5794
Practice Address - Fax:414-351-2770
Is Sole Proprietor?:No
Enumeration Date:2016-02-01
Last Update Date:2016-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2425-19225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant