Healthcare Provider Details

I. General information

NPI: 1174006092
Provider Name (Legal Business Name): NICOLE ANN ANDERSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: NICOLE ANN ROTTER

II. Dates (important events)

Enumeration Date: 09/07/2018
Last Update Date: 01/26/2022
Certification Date: 01/26/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

N6280 CTY RD C
CECIL WI
54111-9344
US

IV. Provider business mailing address

N6280 COUNTY ROAD C
CECIL WI
54111-9344
US

V. Phone/Fax

Practice location:
  • Phone: 920-639-1274
  • Fax:
Mailing address:
  • Phone: 920-639-1274
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WH0200X
TaxonomyHome Health Registered Nurse
License Number236237-30
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: