Provider Demographics
NPI:1871216051
Name:DUTTER, NICHOLE CHRISTINE (APNP)
Entity type:Individual
Prefix:
First Name:NICHOLE
Middle Name:CHRISTINE
Last Name:DUTTER
Suffix:
Gender:F
Credentials:APNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:630 LAKE DR
Mailing Address - Street 2:
Mailing Address - City:RANDOM LAKE
Mailing Address - State:WI
Mailing Address - Zip Code:53075-1766
Mailing Address - Country:US
Mailing Address - Phone:920-912-3742
Mailing Address - Fax:
Practice Address - Street 1:502 HWY 67
Practice Address - Street 2:
Practice Address - City:KIEL
Practice Address - State:WI
Practice Address - Zip Code:53042-1650
Practice Address - Country:US
Practice Address - Phone:920-496-4700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-22
Last Update Date:2023-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI13138-33363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily