Provider Demographics
NPI:1821499369
Name:WILLMS, NICOLE (OT)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:WILLMS
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2500 W LAYTON AVE
Mailing Address - Street 2:SUITE 160
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53221-5420
Mailing Address - Country:US
Mailing Address - Phone:414-389-3023
Mailing Address - Fax:414-817-5745
Practice Address - Street 1:2500 W LAYTON AVE
Practice Address - Street 2:SUITE 160
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53221-5420
Practice Address - Country:US
Practice Address - Phone:414-389-3023
Practice Address - Fax:414-817-5745
Is Sole Proprietor?:No
Enumeration Date:2014-09-15
Last Update Date:2014-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4797225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist