Healthcare Provider Details

I. General information

NPI: 1396250320
Provider Name (Legal Business Name): NICOLE MANUEL APN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/13/2017
Last Update Date: 10/29/2025
Certification Date: 10/29/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

284 MEMORIAL CT STE B
CRYSTAL LAKE IL
60014-6231
US

IV. Provider business mailing address

600 HART RD STE 100
BARRINGTON IL
60010-2662
US

V. Phone/Fax

Practice location:
  • Phone: 815-477-8900
  • Fax: 815-477-7160
Mailing address:
  • Phone: 815-477-8900
  • Fax: 815-477-7160

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code364SA2200X
TaxonomyAdult Health Clinical Nurse Specialist
License Number209.006547
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number209.006547
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: