Healthcare Provider Details

I. General information

NPI: 1679749667
Provider Name (Legal Business Name): MRS. NICOLE HOLZEM
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/30/2008
Last Update Date: 10/24/2025
Certification Date: 10/24/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3107 WESTHILL DR
WAUSAU WI
54401-3774
US

IV. Provider business mailing address

704 W CROCKER ST
WAUSAU WI
54401-2130
US

V. Phone/Fax

Practice location:
  • Phone: 715-845-8444
  • Fax:
Mailing address:
  • Phone: 715-842-0575
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number1419-019
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: