Provider Demographics
NPI:1659498475
Name:PEDERSON, NICOLE L (DPT)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:L
Last Name:PEDERSON
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:L
Other - Last Name:CUMMINGS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DPT
Mailing Address - Street 1:2600 S WISCONSIN AVENUE
Mailing Address - Street 2:SUITE A
Mailing Address - City:RICE LAKE
Mailing Address - State:WI
Mailing Address - Zip Code:54868-7527
Mailing Address - Country:US
Mailing Address - Phone:715-855-0430
Mailing Address - Fax:
Practice Address - Street 1:2600 S WISCONSIN AVENUE
Practice Address - Street 2:SUITE A
Practice Address - City:RICE LAKE
Practice Address - State:WI
Practice Address - Zip Code:54868-7527
Practice Address - Country:US
Practice Address - Phone:715-236-3610
Practice Address - Fax:715-236-3615
Is Sole Proprietor?:No
Enumeration Date:2007-03-25
Last Update Date:2024-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT6343254-48102255A2300X
WI12439225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer