Provider Demographics
NPI:1740060508
Name:LAMBECK-JOHNSON, NICOLE RENEE
Entity type:Individual
Prefix:MRS
First Name:NICOLE
Middle Name:RENEE
Last Name:LAMBECK-JOHNSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5304 E COUNTY ROAD M
Mailing Address - Street 2:
Mailing Address - City:GORDON
Mailing Address - State:WI
Mailing Address - Zip Code:54838-4102
Mailing Address - Country:US
Mailing Address - Phone:414-232-1658
Mailing Address - Fax:
Practice Address - Street 1:5304 E COUNTY ROAD M
Practice Address - Street 2:
Practice Address - City:GORDON
Practice Address - State:WI
Practice Address - Zip Code:54838-4102
Practice Address - Country:US
Practice Address - Phone:414-232-1658
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-09-29
Last Update Date:2023-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WIL5126367768308172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver