Provider Demographics
NPI:1356395206
Name:POLAND, NICOLE ASHLEY (RCS LPN)
Entity type:Individual
Prefix:MRS
First Name:NICOLE
Middle Name:ASHLEY
Last Name:POLAND
Suffix:
Gender:F
Credentials:RCS LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:643 SHORT ST
Mailing Address - Street 2:
Mailing Address - City:FORT ATKINSON
Mailing Address - State:WI
Mailing Address - Zip Code:53538-1457
Mailing Address - Country:US
Mailing Address - Phone:608-212-1791
Mailing Address - Fax:
Practice Address - Street 1:519 HANNERVILLE RD
Practice Address - Street 2:
Practice Address - City:STOUGHTON
Practice Address - State:WI
Practice Address - Zip Code:53589-4318
Practice Address - Country:US
Practice Address - Phone:608-873-2821
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-22
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38340200Medicaid