Provider Demographics
NPI:1912109331
Name:WELLENSIEK, NICOLE SUZANNE (OD)
Entity Type:Individual
Prefix:DR
First Name:NICOLE
Middle Name:SUZANNE
Last Name:WELLENSIEK
Suffix:
Gender:F
Credentials:OD
Other - Prefix:DR
Other - First Name:NICOLE
Other - Middle Name:SUZANNE
Other - Last Name:ROBINS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OD
Mailing Address - Street 1:1861 WADSWORTH BLVD
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:CO
Mailing Address - Zip Code:80214-5225
Mailing Address - Country:US
Mailing Address - Phone:303-237-5401
Mailing Address - Fax:303-237-9638
Practice Address - Street 1:1861 WADSWORTH BLVD
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:CO
Practice Address - Zip Code:80214-5225
Practice Address - Country:US
Practice Address - Phone:303-237-5401
Practice Address - Fax:303-237-9638
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-05
Last Update Date:2022-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COCO2447152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
U69759Medicare UPIN