Provider Demographics
NPI:1790088672
Name:PROKASH, NICOLE ANN (MS)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:ANN
Last Name:PROKASH
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:543 HILL RD
Mailing Address - Street 2:
Mailing Address - City:GREENLEAF
Mailing Address - State:WI
Mailing Address - Zip Code:54126-9632
Mailing Address - Country:US
Mailing Address - Phone:920-205-9757
Mailing Address - Fax:
Practice Address - Street 1:1040 PILGRIM WAY
Practice Address - Street 2:
Practice Address - City:ASHWAUBENON
Practice Address - State:WI
Practice Address - Zip Code:54304-5028
Practice Address - Country:US
Practice Address - Phone:920-405-3522
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-12-14
Last Update Date:2022-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4928-026225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist