Provider Demographics
NPI:1588118087
Name:HORN, NICOLE L (APNP)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:L
Last Name:HORN
Suffix:
Gender:F
Credentials:APNP
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:
Other - Last Name:KRUEGER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:APNP
Mailing Address - Street 1:PO BOX 735044
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60673-5044
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2901 W KINNICKINNIC RIVER PKWY
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53215-3677
Practice Address - Country:US
Practice Address - Phone:414-649-3780
Practice Address - Fax:414-649-3794
Is Sole Proprietor?:No
Enumeration Date:2016-08-12
Last Update Date:2023-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI7167363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100065052Medicaid
WIK400390380OtherMEDICARE
WI1588118087Medicaid