Healthcare Provider Details

I. General information

NPI: 1730273038
Provider Name (Legal Business Name): HEATHER MARITA NICCOLI HS3
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/03/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2420 S LINCOLN MEMORIAL DR USCG SECTOR LAKE MICHIGAN-MEDICAL
MILWAUKEE WI
53207-1902
US

IV. Provider business mailing address

3431 S 113TH ST APT 3
WEST ALLIS WI
53227-3954
US

V. Phone/Fax

Practice location:
  • Phone: 414-747-7110
  • Fax: 414-747-7891
Mailing address:
  • Phone: 414-747-7110
  • Fax: 414-747-7891

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1710I1003X
TaxonomyIndependent Duty Medical Technicians
License Number1259829
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: