Provider Demographics
NPI:1730273038
Name:NICCOLI, HEATHER MARITA (HS3)
Entity type:Individual
Prefix:MISS
First Name:HEATHER
Middle Name:MARITA
Last Name:NICCOLI
Suffix:
Gender:F
Credentials:HS3
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Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:3431 S 113TH ST APT 3
Mailing Address - Street 2:
Mailing Address - City:WEST ALLIS
Mailing Address - State:WI
Mailing Address - Zip Code:53227-3954
Mailing Address - Country:US
Mailing Address - Phone:414-747-7110
Mailing Address - Fax:414-747-7891
Practice Address - Street 1:2420 S LINCOLN MEMORIAL DR
Practice Address - Street 2:USCG SECTOR LAKE MICHIGAN-MEDICAL
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53207-1902
Practice Address - Country:US
Practice Address - Phone:414-747-7110
Practice Address - Fax:414-747-7891
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA12598291710I1003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1003XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Medical Technicians