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General NPI Number Information
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NPI Number | 1659383040
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Entity Type | Individual
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Provider Name | NICOLE DENAE BENJAMIN REDDICK PA-C
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Gender | Female
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Dates
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Enumeration Date | 08/13/2006
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Last Update Date | 08/12/2024
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Provider Practice Location Address
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Address Line | 100 THEDA CLARK MEDICAL PLZ STE 340
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City | NEENAH
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State | WI
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Zip | 54956-2763
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Country | US
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Telephone | 920-364-3600
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Fax | 920-364-3900
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Provider Business Mailing Address
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Address Line | 100 THEDA CLARK MEDICAL PLZ STE 340
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City | NEENAH
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State | WI
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Zip | 54956-2763
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Country | US
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Telephone | 920-364-3600
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Fax | 920-364-3900
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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 | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number | PA04542
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License Number State | TX
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Taxonomy #2
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number | 2729
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License Number State | WI
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