Provider Demographics
NPI:1679230742
Name:WIENCLAW, NICOLE MARIE (APRN)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:MARIE
Last Name:WIENCLAW
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8 ESSEX WAY STE 201
Mailing Address - Street 2:
Mailing Address - City:ESSEX
Mailing Address - State:VT
Mailing Address - Zip Code:05452-3422
Mailing Address - Country:US
Mailing Address - Phone:802-872-7100
Mailing Address - Fax:
Practice Address - Street 1:8 ESSEX WAY STE 201
Practice Address - Street 2:
Practice Address - City:ESSEX
Practice Address - State:VT
Practice Address - Zip Code:05452-3422
Practice Address - Country:US
Practice Address - Phone:802-872-7100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-11-23
Last Update Date:2022-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY348676363LF0000X
VT101.0135034363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily