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NPI Code Detail

MEDICARE: NICOLE MICHELLE TABATABAI BLYTHE DNP, PMHNP-BC

MEDICARE: NICOLE MICHELLE TABATABAI BLYTHE DNP, PMHNP-BC
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
1363LP0808XPsychiatric/Mental Health Nurse Practitioner209029818IL

General Provider Information

NPI Number : 1710595111
Entity Type Code : Individual
Provider Name (Legal Business Name) : NICOLE MICHELLE TABATABAI BLYTHE DNP, PMHNP-BC
Provider Business Mailing Address
First Line : 25 E WASHINGTON ST STE 1601
Second Line :
City : CHICAGO
State : IL
Zip : 60602-1882
Country : US
Telephone Number : 312-276-4000
Fax Number : 312-276-4000
Provider Business Practice Location Address
First Line : 25 E WASHINGTON ST STE 1601
Second Line :
City : CHICAGO
State : IL
Zip : 60602-1882
Country : US
Telephone Number : 312-450-0313
Fax Number : 312-276-4000
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 07/21/2020
Last Update Date : 04/13/2026

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