Provider Demographics
NPI:1659965606
Name:NICKELSON, JUANITA
Entity Type:Individual
Prefix:
First Name:JUANITA
Middle Name:
Last Name:NICKELSON
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 1:733 STRUCK ST UNIT 45617
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53744-3660
Mailing Address - Country:US
Mailing Address - Phone:414-704-4217
Mailing Address - Fax:
Practice Address - Street 1:2501 MCKENNA BLVD
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53711-3917
Practice Address - Country:US
Practice Address - Phone:414-704-4217
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-21
Last Update Date:2021-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes376G00000XNursing Service Related ProvidersNursing Home AdministratorGroup - Single Specialty