MEDICARE: NICOLE LEE REIS-EIBARA APNP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LF0000X	Family Nurse Practitioner	CNP24682	OH
2	363L00000X	Nurse Practitioner	APRN.CNP.02468	OH

General Provider Information

NPI Number	:	1134782543
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	NICOLE LEE REIS-EIBARA APNP

Provider Business Mailing Address
First Line	:	10001 W INNOVATION DR STE 200
Second Line	:
City	:	MILWAUKEE
State	:	WI
Zip	:	53226-4851
Country	:	US
Telephone Number	:	888-938-3838
Fax Number	:	888-919-1083

Provider Business Practice Location Address
First Line	:	6531 MARKET AVE N STE 100
Second Line	:
City	:	CANTON
State	:	OH
Zip	:	44721-2430
Country	:	US
Telephone Number	:	888-938-3838
Fax Number	:	888-919-1083

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/22/2019
Last Update Date	:	03/25/2026

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