Healthcare Provider Details

I. General information

NPI: 1013319623
Provider Name (Legal Business Name): NICOLE M LORD APRN, CNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: NICOLE M ULM

II. Dates (important events)

Enumeration Date: 09/25/2014
Last Update Date: 12/05/2024
Certification Date: 12/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1730 BRADFORD LN
NORMAL IL
61761-1297
US

IV. Provider business mailing address

1730 BRADFORD LN
NORMAL IL
61761-1297
US

V. Phone/Fax

Practice location:
  • Phone: 309-451-2080
  • Fax:
Mailing address:
  • Phone: 309-451-2080
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number277001436
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number309007641
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: