Healthcare Provider Details

I. General information

NPI: 1295186310
Provider Name (Legal Business Name): TATUM NICHOLS PT, DPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/30/2016
Last Update Date: 06/07/2021
Certification Date: 06/07/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

110 CARVER LN
EAST PEORIA IL
61611-3052
US

IV. Provider business mailing address

110 CARVER LN
EAST PEORIA IL
61611-3052
US

V. Phone/Fax

Practice location:
  • Phone: 309-282-6704
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number070.025835
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: