Healthcare Provider Details

I. General information

NPI: 1598679516
Provider Name (Legal Business Name): COURTNEY KEYONNA NICHOLS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/29/2026
Last Update Date: 09/29/2026
Certification Date: 09/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4321 S SAINT LAWRENCE AVE APT 2S
CHICAGO IL
60653-2730
US

IV. Provider business mailing address

4321 S SAINT LAWRENCE AVE UNIT 2
CHICAGO IL
60653-2730
US

V. Phone/Fax

Practice location:
  • Phone: 312-636-0101
  • Fax:
Mailing address:
  • Phone: 312-636-0101
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number041513709
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: