Healthcare Provider Details

I. General information

NPI: 1659383040
Provider Name (Legal Business Name): NICOLE DENAE BENJAMIN REDDICK PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: NICOLE DENAE BENJAMIN

II. Dates (important events)

Enumeration Date: 08/13/2006
Last Update Date: 08/12/2024
Certification Date: 08/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 THEDA CLARK MEDICAL PLZ STE 340
NEENAH WI
54956-2763
US

IV. Provider business mailing address

100 THEDA CLARK MEDICAL PLZ STE 340
NEENAH WI
54956-2763
US

V. Phone/Fax

Practice location:
  • Phone: 920-364-3600
  • Fax: 920-364-3900
Mailing address:
  • Phone: 920-364-3600
  • Fax: 920-364-3900

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA04542
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number2729
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: