Provider Demographics
NPI:1346480803
Name:DEVRIES, NICOLE A (LPN)
Entity type:Individual
Prefix:MRS
First Name:NICOLE
Middle Name:A
Last Name:DEVRIES
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:206 MARY ST
Mailing Address - Street 2:
Mailing Address - City:BEAVER DAM
Mailing Address - State:WI
Mailing Address - Zip Code:53916-1510
Mailing Address - Country:US
Mailing Address - Phone:920-296-6877
Mailing Address - Fax:
Practice Address - Street 1:206 MARY ST
Practice Address - Street 2:
Practice Address - City:BEAVER DAM
Practice Address - State:WI
Practice Address - Zip Code:53916-1510
Practice Address - Country:US
Practice Address - Phone:920-296-6877
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-02-24
Last Update Date:2009-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI303194-031164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse