Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225200000X | Physical Therapy Assistant | 293 | WI |
NPI | 1023107729 |
---|---|
Provider Name | Melissa Kay Nickels |
First Address | Sauk City, WI 53583-1381 |
Second Address | Sauk City, WI 53583-1381 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 12/10/2006 |
Last Update Date | 08/07/2007 |