Healthcare Provider Details

I. General information

NPI: 1740712090
Provider Name (Legal Business Name): NICOLE VICTOR FNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: NICOLE LESIAK

II. Dates (important events)

Enumeration Date: 03/28/2017
Last Update Date: 11/06/2025
Certification Date: 11/06/2025
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: 708-520-1875
Mailing address:
  • Phone: 847-390-5900
  • Fax: 847-390-4757

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number209.015750
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number209.015750
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: