Provider Demographics
NPI:1790220044
Name:KAKUK, NICOLE ANN (APRN)
Entity type:Individual
Prefix:MRS
First Name:NICOLE
Middle Name:ANN
Last Name:KAKUK
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2300 WESTERN AVE
Mailing Address - Street 2:
Mailing Address - City:MANITOWOC
Mailing Address - State:WI
Mailing Address - Zip Code:54220-3712
Mailing Address - Country:US
Mailing Address - Phone:920-320-2011
Mailing Address - Fax:
Practice Address - Street 1:2300 WESTERN AVE
Practice Address - Street 2:
Practice Address - City:MANITOWOC
Practice Address - State:WI
Practice Address - Zip Code:54220-3712
Practice Address - Country:US
Practice Address - Phone:920-320-2011
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-12-22
Last Update Date:2024-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI232814 - 30163W00000X
WI319942164X00000X
WI12223-33363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered Nurse
No164X00000XNursing Service ProvidersLicensed Vocational Nurse