Healthcare Provider Details

I. General information

NPI: 1922329507
Provider Name (Legal Business Name): NICOLE M CHICKRIS-BOLLAERT MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/17/2010
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5401 44TH AVENUE DR STE 101
MOLINE IL
61265-8126
US

IV. Provider business mailing address

525 VALLEY VIEW DR
MOLINE IL
61265-6138
US

V. Phone/Fax

Practice location:
  • Phone: 309-779-4050
  • Fax:
Mailing address:
  • Phone: 309-792-9869
  • Fax: 309-762-2313

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number125058663
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number036.130996
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: