Provider Demographics
NPI:1720109143
Name:ROSS, NICOLE R (MS, ATC, LAT)
Entity type:Individual
Prefix:MRS
First Name:NICOLE
Middle Name:R
Last Name:ROSS
Suffix:
Gender:F
Credentials:MS, ATC, LAT
Other - Prefix:MISS
Other - First Name:NICOLE
Other - Middle Name:R
Other - Last Name:HUMANN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1950 PINE RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:ONALASKA
Mailing Address - State:WI
Mailing Address - Zip Code:54650-2027
Mailing Address - Country:US
Mailing Address - Phone:607-222-6073
Mailing Address - Fax:
Practice Address - Street 1:1725 STATE ST
Practice Address - Street 2:
Practice Address - City:LA CROSSE
Practice Address - State:WI
Practice Address - Zip Code:54601-3742
Practice Address - Country:US
Practice Address - Phone:607-222-6073
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-03
Last Update Date:2024-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1662-392255A2300X
2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic TrainerGroup - Single Specialty