Provider Demographics
NPI:1528644036
Name:LANKEY, NICOLE LEE (PA)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:LEE
Last Name:LANKEY
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:COLEY
Other - Middle Name:LEE
Other - Last Name:LANKEY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PA
Mailing Address - Street 1:PO BOX 249
Mailing Address - Street 2:
Mailing Address - City:FORT ATKINSON
Mailing Address - State:WI
Mailing Address - Zip Code:53538-0249
Mailing Address - Country:US
Mailing Address - Phone:920-563-4466
Mailing Address - Fax:
Practice Address - Street 1:512 WILCOX ST
Practice Address - Street 2:
Practice Address - City:FORT ATKINSON
Practice Address - State:WI
Practice Address - Zip Code:53538-1254
Practice Address - Country:US
Practice Address - Phone:920-563-6667
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-23
Last Update Date:2022-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
WI5802-23363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program