Healthcare Provider Details

I. General information

NPI: 1093781452
Provider Name (Legal Business Name): GLENN A NICKELE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/27/2006
Last Update Date: 06/12/2024
Certification Date: 06/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

216 S ADAMS ST
SAINT CROIX FALLS WI
54024-9449
US

IV. Provider business mailing address

235 STATE STREET
ST. CROIX FALLS WI
54024-4117
US

V. Phone/Fax

Practice location:
  • Phone: 715-483-3221
  • Fax: 715-483-0507
Mailing address:
  • Phone: 715-483-3261
  • Fax: 715-483-0507

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number42548
License Number StateMN
# 2
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number32220
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: