Basic Information
| Provider Information | |||||||||
| NPI: | 1053067025 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | REITZNER | ||||||||
| FirstName: | NICOLE | ||||||||
| MiddleName: | MAE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 10001 W INNOVATION DR STE 200 | ||||||||
| Address2: | |||||||||
| City: | MILWAUKEE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532264851 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8889383838 | ||||||||
| FaxNumber: | 8889191083 | ||||||||
| Practice Location | |||||||||
| Address1: | 500 W DREXEL AVE STE 300 | ||||||||
| Address2: | |||||||||
| City: | OAK CREEK | ||||||||
| State: | WI | ||||||||
| PostalCode: | 531542060 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8889383838 | ||||||||
| FaxNumber: | 8889191083 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/28/2022 | ||||||||
| LastUpdateDate: | 08/08/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 08/08/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 363A00000X | 7006 | WI | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.