Provider Demographics
NPI:1871822049
Name:CREIGHTON, NICOLE TERESE (RN)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:TERESE
Last Name:CREIGHTON
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:TERESE
Other - Last Name:ANDERSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:325 WILSON AVE
Mailing Address - Street 2:
Mailing Address - City:WAUKESHA
Mailing Address - State:WI
Mailing Address - Zip Code:53186-6103
Mailing Address - Country:US
Mailing Address - Phone:414-861-1723
Mailing Address - Fax:
Practice Address - Street 1:325 WILSON AVE
Practice Address - Street 2:
Practice Address - City:WAUKESHA
Practice Address - State:WI
Practice Address - Zip Code:53186-6103
Practice Address - Country:US
Practice Address - Phone:414-861-1723
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-12-16
Last Update Date:2009-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI138378-030163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI35025300Medicaid