Healthcare Provider Details

I. General information

NPI: 1083524557
Provider Name (Legal Business Name): NICHOLAS WILLIAM HUMMEL DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/08/2026
Last Update Date: 09/08/2026
Certification Date: 09/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1106 ANNAPOLIS RD STE 120
ODENTON MD
21113-1738
US

IV. Provider business mailing address

167 EDMUND DR
GREEN BAY WI
54302-5202
US

V. Phone/Fax

Practice location:
  • Phone: 443-481-1140
  • Fax:
Mailing address:
  • Phone: 920-883-8465
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number17739-24
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: