Healthcare Provider Details

I. General information

NPI: 1457459869
Provider Name (Legal Business Name): NICHOLE VIRGO APNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/20/2006
Last Update Date: 05/02/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8901 N 76TH ST FL 3
MILWAUKEE WI
53223-1901
US

IV. Provider business mailing address

1225 W PINE CREEK CT
OAK CREEK WI
53154-1833
US

V. Phone/Fax

Practice location:
  • Phone: 414-357-1307
  • Fax: 414-365-0773
Mailing address:
  • Phone: 414-745-5158
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License Number148802
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number3323-33
License Number StateWI
# 3
Primary TaxonomyN
Taxonomy Code367A00000X
TaxonomyAdvanced Practice Midwife
License Number139386-30
License Number StateWI
# 4
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number3323
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: