Healthcare Provider Details

I. General information

NPI: 1104873280
Provider Name (Legal Business Name): ELLEN PUSKALA NICKEL APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/27/2006
Last Update Date: 06/08/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2500 OVERLOOK TER
MADISON WI
53705-2254
US

IV. Provider business mailing address

3966 SUNNYVALE DR
DE FOREST WI
53532-2747
US

V. Phone/Fax

Practice location:
  • Phone: 608-280-7066
  • Fax: 308-280-7020
Mailing address:
  • Phone: 608-256-1901
  • Fax: 608-280-7020

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number502
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: