Provider Demographics
NPI:1790052397
Name:FISKE, NICOLE ELAINE (DO)
Entity Type:Individual
Prefix:DR
First Name:NICOLE
Middle Name:ELAINE
Last Name:FISKE
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7777 HENNESSY BLVD STE 211
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70808-4365
Mailing Address - Country:US
Mailing Address - Phone:225-765-7163
Mailing Address - Fax:225-765-7164
Practice Address - Street 1:7777 HENNESSY BLVD STE 211
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70808-4365
Practice Address - Country:US
Practice Address - Phone:225-765-7163
Practice Address - Fax:225-765-7164
Is Sole Proprietor?:No
Enumeration Date:2011-11-27
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH390200000X
LADO.000464207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program