Healthcare Provider Details

I. General information

NPI: 1265830442
Provider Name (Legal Business Name): THELMA MICHELLE HOLT-NICHOLSON FNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/20/2014
Last Update Date: 06/08/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1340 S DAMEN AVE
CHICAGO IL
60608-1169
US

IV. Provider business mailing address

P O BOX 2114
MATTESON IL
60443
US

V. Phone/Fax

Practice location:
  • Phone: 877-663-1333
  • Fax:
Mailing address:
  • Phone: 877-663-1333
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number209.012271
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: