Healthcare Provider Details

I. General information

NPI: 1326456815
Provider Name (Legal Business Name): NICOLE REZACHEK PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/28/2014
Last Update Date: 07/28/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

N27W5707 LINCOLN BLVD
CEDARBURG WI
53012-2852
US

IV. Provider business mailing address

N27W5707 LINCOLN BLVD
CEDARBURG WI
53012-2852
US

V. Phone/Fax

Practice location:
  • Phone: 262-376-7676
  • Fax: 262-376-5208
Mailing address:
  • Phone: 262-376-7676
  • Fax: 262-376-5208

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number2197-19
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: