Provider Demographics
NPI:1639683220
Name:RIETVELD, NICCOLE (PTA)
Entity Type:Individual
Prefix:
First Name:NICCOLE
Middle Name:
Last Name:RIETVELD
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 1:6361 S 27TH ST LOT 24
Mailing Address - Street 2:
Mailing Address - City:FRANKLIN
Mailing Address - State:WI
Mailing Address - Zip Code:53132-9410
Mailing Address - Country:US
Mailing Address - Phone:414-531-5176
Mailing Address - Fax:
Practice Address - Street 1:8800 W LINCOLN AVE
Practice Address - Street 2:
Practice Address - City:WEST ALLIS
Practice Address - State:WI
Practice Address - Zip Code:53227-2400
Practice Address - Country:US
Practice Address - Phone:414-541-1118
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-11-19
Last Update Date:2017-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2652-19225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant