Healthcare Provider Details

I. General information

NPI: 1942560016
Provider Name (Legal Business Name): NICHOLE MICHELE GEBERT RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/23/2012
Last Update Date: 05/23/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5343 BEAVER DAM RD
WEST BEND WI
53090-9383
US

IV. Provider business mailing address

5343 BEAVER DAM RD
WEST BEND WI
53090-9383
US

V. Phone/Fax

Practice location:
  • Phone: 262-442-5540
  • Fax:
Mailing address:
  • Phone: 262-442-5540
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number183674-30
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: