Provider Demographics
NPI:1992105621
Name:HALL, NICOLE R (NP)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:R
Last Name:HALL
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:
Other - Last Name:BOEDEKER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2901 W KINNICKINNIC RIVER PKWY
Mailing Address - Street 2:511
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53215
Mailing Address - Country:US
Mailing Address - Phone:414-649-3780
Mailing Address - Fax:
Practice Address - Street 1:2901 S KINNICKINNIC AVE
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53215
Practice Address - Country:US
Practice Address - Phone:414-646-3985
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-08-29
Last Update Date:2021-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5951363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI5951-33OtherSTATE