Healthcare Provider Details

I. General information

NPI: 1215856695
Provider Name (Legal Business Name): NICOLE R LOPEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/10/2026
Last Update Date: 08/12/2026
Certification Date: 08/12/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

389 E MAIN ST
BRAIDWOOD IL
60408-2010
US

IV. Provider business mailing address

725 SCHOOL ST STE A
MORRIS IL
60450-1207
US

V. Phone/Fax

Practice location:
  • Phone: 815-458-2532
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number209.035840
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number209.035840
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: