Provider Demographics
NPI:1649521345
Name:WHITE, NICOLE (NP)
Entity type:Individual
Prefix:MRS
First Name:NICOLE
Middle Name:
Last Name:WHITE
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3003 W GOOD HOPE RD
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53209-2042
Mailing Address - Country:US
Mailing Address - Phone:414-352-3100
Mailing Address - Fax:
Practice Address - Street 1:975 PORT WASHINGTON RD
Practice Address - Street 2:SUITE 320
Practice Address - City:GRAFTON
Practice Address - State:WI
Practice Address - Zip Code:53024-9201
Practice Address - Country:US
Practice Address - Phone:262-329-8100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-09-21
Last Update Date:2013-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5052-33363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner