Healthcare Provider Details

I. General information

NPI: 1376284091
Provider Name (Legal Business Name): NICOLE GAZDZIK
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/05/2022
Last Update Date: 03/24/2026
Certification Date: 03/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5841 S MARYLAND AVE
CHICAGO IL
60637-1443
US

IV. Provider business mailing address

477 N 400 E
VALPARAISO IN
46383-9707
US

V. Phone/Fax

Practice location:
  • Phone: 773-702-6149
  • Fax: 773-753-0581
Mailing address:
  • Phone: 219-241-9311
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number041.418982
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number209024080
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number28210053A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: