Provider Demographics
NPI:1992762835
Name:AMIDON, NICOLE L (OD)
Entity type:Individual
Prefix:DR
First Name:NICOLE
Middle Name:L
Last Name:AMIDON
Suffix:
Gender:F
Credentials:OD
Other - Prefix:MISS
Other - First Name:NICOLE
Other - Middle Name:LYNN
Other - Last Name:BOUDRY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:16800 WEST CLEVELAND AVE
Mailing Address - Street 2:
Mailing Address - City:NEW BERLIN
Mailing Address - State:WI
Mailing Address - Zip Code:53151-3533
Mailing Address - Country:US
Mailing Address - Phone:262-432-2005
Mailing Address - Fax:
Practice Address - Street 1:459 W JOHNSON ST
Practice Address - Street 2:
Practice Address - City:FOND DU LAC
Practice Address - State:WI
Practice Address - Zip Code:54935-3170
Practice Address - Country:US
Practice Address - Phone:920-922-5990
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-26
Last Update Date:2007-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2758-.035152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI2758OtherEYEMED VISION NO.
WI38611200Medicaid
WI2758OtherEYEMED VISION NO.