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General NPI Number Information
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NPI Number | 1225187610
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Entity Type | Individual
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Provider Name | NICKEY LOUIS WOLFF L.A.T.
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Gender | Male
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Dates
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Enumeration Date | 01/09/2007
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Last Update Date | 07/08/2007
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Provider Practice Location Address
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Address Line | N63W23075 STATE HIGHWAY 74
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City | SUSSEX
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State | WI
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Zip | 53089-2876
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Country | US
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Telephone | 414-566-4586
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Fax | 414-566-4640
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Provider Business Mailing Address
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Address Line | 2757 N 74TH ST
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City | WAUWATOSA
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State | WI
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Zip | 53210-1009
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Country | US
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Telephone | 414-774-2658
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2255A2300X
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Taxonomy Name | Athletic Trainer
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License Number | 95-039
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License Number State | WI
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