Healthcare Provider Details

I. General information

NPI: 1942479647
Provider Name (Legal Business Name): NICOLE MARIE GRANEY FPA NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/27/2008
Last Update Date: 04/30/2026
Certification Date: 04/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4440 W 95TH ST STE 6409
OAK LAWN IL
60453-2600
US

IV. Provider business mailing address

29373 NETWORK PL
CHICAGO IL
60673-1293
US

V. Phone/Fax

Practice location:
  • Phone: 877-684-4327
  • Fax: 708-520-1871
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number277-005387
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: