Provider Demographics
NPI:1891918090
Name:NICKELS, MICHELE (NMD, LAC)
Entity Type:Individual
Prefix:
First Name:MICHELE
Middle Name:
Last Name:NICKELS
Suffix:
Gender:F
Credentials:NMD, LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16535 W BLUEMOUND RD STE 222
Mailing Address - Street 2:
Mailing Address - City:BROOKFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:53005-5906
Mailing Address - Country:US
Mailing Address - Phone:262-754-4910
Mailing Address - Fax:
Practice Address - Street 1:16535 W BLUEMOUND RD STE 222
Practice Address - Street 2:
Practice Address - City:BROOKFIELD
Practice Address - State:WI
Practice Address - Zip Code:53005-5906
Practice Address - Country:US
Practice Address - Phone:262-754-4910
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-10
Last Update Date:2008-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI499-055171100000X
AZ03-728175F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175F00000XOther Service ProvidersNaturopath
No171100000XOther Service ProvidersAcupuncturist