Provider Demographics
NPI:1134817760
Name:PHILLIPS, NICOLE JANE (RN, BSN, CLC)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:JANE
Last Name:PHILLIPS
Suffix:
Gender:F
Credentials:RN, BSN, CLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2358 JOURDAIN LN
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54301-2138
Mailing Address - Country:US
Mailing Address - Phone:920-360-1111
Mailing Address - Fax:
Practice Address - Street 1:1300 W MAIN AVE
Practice Address - Street 2:
Practice Address - City:DE PERE
Practice Address - State:WI
Practice Address - Zip Code:54115-9366
Practice Address - Country:US
Practice Address - Phone:920-336-6594
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-01
Last Update Date:2023-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI184153-30163WL0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WL0100XNursing Service ProvidersRegistered NurseLactation Consultant