Healthcare Provider Details

I. General information

NPI: 1710595111
Provider Name (Legal Business Name): NICOLE MICHELLE TABATABAI BLYTHE DNP, PMHNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/21/2020
Last Update Date: 09/04/2024
Certification Date: 09/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

159 N SANGAMON ST RM 266
CHICAGO IL
60607-2201
US

IV. Provider business mailing address

1400 W RANDOLPH ST UNIT 1402
CHICAGO IL
60607-1434
US

V. Phone/Fax

Practice location:
  • Phone: 516-505-7200
  • Fax:
Mailing address:
  • Phone: 217-622-4976
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number209029818
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: