MEDICARE: DR. NICOLE DAWN VILLARREAL MD

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	208000000X	Pediatrics Physician	MD28338	OR
2	208000000X	Pediatrics Physician	MD600090646	WA
3	208000000X	Pediatrics Physician	39803	IA

General Provider Information

NPI Number	:	1568659423
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. NICOLE DAWN VILLARREAL MD

Provider Business Mailing Address
First Line	:	16856 OAK VALLEY RD
Second Line	:
City	:	CRESCENT
State	:	IA
Zip	:	51526-4226
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	16856 OAK VALLEY RD
Second Line	:
City	:	CRESCENT
State	:	IA
Zip	:	51526-4226
Country	:	US
Telephone Number	:	712-545-9075
Fax Number	:

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

Provider Enumeration Date	:	09/25/2007
Last Update Date	:	07/13/2015

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