Healthcare Provider Details

I. General information

NPI: 1720862055
Provider Name (Legal Business Name): NICOLE A ULI RN APN NP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/18/2023
Last Update Date: 08/18/2023
Certification Date: 08/18/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1875 DEMPSTER ST STE 110
PARK RIDGE IL
60068-1125
US

IV. Provider business mailing address

1875 DEMPSTER ST STE 110
PARK RIDGE IL
60068-1125
US

V. Phone/Fax

Practice location:
  • Phone: 847-897-9010
  • Fax: 847-692-2129
Mailing address:
  • Phone: 847-897-9010
  • Fax: 847-692-2129

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WG0000X
TaxonomyGeneral Practice Registered Nurse
License Number041369546
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number2017035984
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: