Provider Demographics
NPI:1700269057
Name:BURNETT, NICOLE (DNP, APNP, FNP-BC)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:BURNETT
Suffix:
Gender:F
Credentials:DNP, APNP, FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2527 OLE DAVIDSON RD
Mailing Address - Street 2:
Mailing Address - City:MOUNT PLEASANT
Mailing Address - State:WI
Mailing Address - Zip Code:53405-1442
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6127 GREEN BAY RD STE 100
Practice Address - Street 2:
Practice Address - City:KENOSHA
Practice Address - State:WI
Practice Address - Zip Code:53142-2941
Practice Address - Country:US
Practice Address - Phone:262-652-2887
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-07-06
Last Update Date:2020-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI6425-33363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100046073Medicaid