Provider Demographics
NPI:1457459869
Name:VIRGO, NICHOLE (APNP)
Entity Type:Individual
Prefix:
First Name:NICHOLE
Middle Name:
Last Name:VIRGO
Suffix:
Gender:F
Credentials:APNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1225 W PINE CREEK CT
Mailing Address - Street 2:
Mailing Address - City:OAK CREEK
Mailing Address - State:WI
Mailing Address - Zip Code:53154-1833
Mailing Address - Country:US
Mailing Address - Phone:414-745-5158
Mailing Address - Fax:
Practice Address - Street 1:8901 N 76TH ST FL 3
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53223-1901
Practice Address - Country:US
Practice Address - Phone:414-357-1307
Practice Address - Fax:414-365-0773
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2018-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI148802208VP0014X
WI3323-33363L00000X
WI139386-30367A00000X
WI3323363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain Medicine
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
WIK400388476OtherMEDICARE
WIV620-6377-9730-09OtherWI DRIVERS LICENSE #