Provider Demographics
NPI:1821533621
Name:WISNASKY, NICHOLE (SLP)
Entity Type:Individual
Prefix:
First Name:NICHOLE
Middle Name:
Last Name:WISNASKY
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5403 DIXON DR
Mailing Address - Street 2:
Mailing Address - City:GODFREY
Mailing Address - State:IL
Mailing Address - Zip Code:62035-1402
Mailing Address - Country:US
Mailing Address - Phone:618-791-7267
Mailing Address - Fax:
Practice Address - Street 1:5403 DIXON DR
Practice Address - Street 2:
Practice Address - City:GODFREY
Practice Address - State:IL
Practice Address - Zip Code:62035-1402
Practice Address - Country:US
Practice Address - Phone:618-791-7267
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-01-03
Last Update Date:2017-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2016044881235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist