Healthcare Provider Details

I. General information

NPI: 1760143762
Provider Name (Legal Business Name): NICOLETTE SMITH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/03/2022
Last Update Date: 09/27/2023
Certification Date: 09/27/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

225 E CHICAGO AVE
CHICAGO IL
60611-2991
US

IV. Provider business mailing address

240 E HURON ST STE 1-200 PA PROGRAM
CHICAGO IL
60611-2909
US

V. Phone/Fax

Practice location:
  • Phone: 312-227-4000
  • Fax:
Mailing address:
  • Phone: 312-503-1851
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number085.009812
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: