Healthcare Provider Details

I. General information

NPI: 1619829223
Provider Name (Legal Business Name): NICOLE NEWTON APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/14/2026
Last Update Date: 08/16/2026
Certification Date: 08/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

331 W SURF ST STE 712
CHICAGO IL
60657-7227
US

IV. Provider business mailing address

331 W SURF ST STE 712
CHICAGO IL
60657-7227
US

V. Phone/Fax

Practice location:
  • Phone: 773-525-0000
  • Fax:
Mailing address:
  • Phone: 773-525-0000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number209034717
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: