Provider Demographics
NPI:1831826874
Name:WACKERLE, NICOLE (RRT)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:WACKERLE
Suffix:
Gender:F
Credentials:RRT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5731 CARLETON ROCKWOOD RD
Mailing Address - Street 2:
Mailing Address - City:SOUTH ROCKWOOD
Mailing Address - State:MI
Mailing Address - Zip Code:48179-9304
Mailing Address - Country:US
Mailing Address - Phone:734-250-1986
Mailing Address - Fax:
Practice Address - Street 1:2333 BIDDLE AVE FL 8
Practice Address - Street 2:
Practice Address - City:WYANDOTTE
Practice Address - State:MI
Practice Address - Zip Code:48192-4668
Practice Address - Country:US
Practice Address - Phone:734-246-5500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-01
Last Update Date:2022-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4401007260227900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes227900000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRespiratory Therapist, Registered