MEDICARE: MISS HEATHER MARITA NICCOLI HS3

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1710I1003X	Independent Duty Medical Technicians	1259829	CA

General Provider Information

NPI Number	:	1730273038
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MISS HEATHER MARITA NICCOLI HS3

Provider Business Mailing Address
First Line	:	3431 S 113TH ST APT 3
Second Line	:
City	:	WEST ALLIS
State	:	WI
Zip	:	53227-3954
Country	:	US
Telephone Number	:	414-747-7110
Fax Number	:	414-747-7891

Provider Business Practice Location Address
First Line	:	2420 S LINCOLN MEMORIAL DR
Second Line	:	USCG SECTOR LAKE MICHIGAN-MEDICAL
City	:	MILWAUKEE
State	:	WI
Zip	:	53207-1902
Country	:	US
Telephone Number	:	414-747-7110
Fax Number	:	414-747-7891

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/03/2006
Last Update Date	:	07/08/2007

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