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General NPI Number Information
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NPI Number | 1639683220
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Entity Type | Individual
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Provider Name | NICCOLE RIETVELD PTA
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Gender | Female
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Dates
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Enumeration Date | 11/19/2017
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Last Update Date | 11/19/2017
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Provider Practice Location Address
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Address Line | 8800 W LINCOLN AVE
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City | WEST ALLIS
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State | WI
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Zip | 53227-2400
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Country | US
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Telephone | 414-541-1118
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Fax |
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Provider Business Mailing Address
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Address Line | 6361 S 27TH ST LOT 24
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City | FRANKLIN
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State | WI
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Zip | 53132-9410
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Country | US
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Telephone | 414-531-5176
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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 | 225200000X
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Taxonomy Name | Physical Therapy Assistant
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License Number | 2652-19
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License Number State | WI
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