Provider Demographics
NPI:1104914951
Name:BALLINGER, NICOLE (DO)
Entity type:Individual
Prefix:DR
First Name:NICOLE
Middle Name:
Last Name:BALLINGER
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1220 DEWEY AVE
Mailing Address - Street 2:
Mailing Address - City:WAUWATOSA
Mailing Address - State:WI
Mailing Address - Zip Code:53213-2504
Mailing Address - Country:US
Mailing Address - Phone:414-454-6600
Mailing Address - Fax:414-454-6766
Practice Address - Street 1:1220 DEWEY AVE
Practice Address - Street 2:
Practice Address - City:WAUWATOSA
Practice Address - State:WI
Practice Address - Zip Code:53213
Practice Address - Country:US
Practice Address - Phone:414-454-6600
Practice Address - Fax:414-454-6766
Is Sole Proprietor?:No
Enumeration Date:2006-10-10
Last Update Date:2021-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI52794-021207Q00000X, 2084P0804X, 2084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine