Provider Demographics
NPI:1629218417
Name:JUEDES, NICOLE E (CST)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:E
Last Name:JUEDES
Suffix:
Gender:F
Credentials:CST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2105 E. ENTERPRISE AVE.
Mailing Address - Street 2:SUITE 111
Mailing Address - City:APPLETON
Mailing Address - State:WI
Mailing Address - Zip Code:54913-7862
Mailing Address - Country:US
Mailing Address - Phone:920-731-6611
Mailing Address - Fax:920-731-6732
Practice Address - Street 1:2105 E. ENTERPRISE AVE.
Practice Address - Street 2:SUITE 111
Practice Address - City:APPLETON
Practice Address - State:WI
Practice Address - Zip Code:54913-7862
Practice Address - Country:US
Practice Address - Phone:920-731-6611
Practice Address - Fax:920-731-6732
Is Sole Proprietor?:No
Enumeration Date:2009-03-06
Last Update Date:2014-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI111971246ZS0410X
246ZS0410X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZS0410XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Technologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
111971OtherNATIONAL BOARD OF SURGICAL TECHNOLOGY AND SURGICAL ASSISTING
140411OtherNATIONAL BOARD OF SURGICAL TECHNOLOGY AND SURGICAL ASSISTING