Healthcare Provider Details

I. General information

NPI: 1740955749
Provider Name (Legal Business Name): NICOLE E NOONAN NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/11/2021
Last Update Date: 01/18/2023
Certification Date: 01/18/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

641 W 63RD ST
CHICAGO IL
60621-2032
US

IV. Provider business mailing address

641 W 63RD ST
CHICAGO IL
60621-2032
US

V. Phone/Fax

Practice location:
  • Phone: 773-388-1600
  • Fax: 773-388-8936
Mailing address:
  • Phone: 773-388-1600
  • Fax: 773-388-8936

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number209023422
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: