Healthcare Provider Details

I. General information

NPI: 1164352688
Provider Name (Legal Business Name): NICKOU MEMARI
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/19/2026
Last Update Date: 05/19/2026
Certification Date: 05/19/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3216 BUSINESS PARK DR
STEVENS POINT WI
54482-8838
US

IV. Provider business mailing address

3518 SOUTHWOOD CT
DAVIE FL
33328-6963
US

V. Phone/Fax

Practice location:
  • Phone: 715-544-1277
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: