Healthcare Provider Details

I. General information

NPI: 1487201877
Provider Name (Legal Business Name): NICOLE R HEUN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/21/2019
Last Update Date: 08/22/2023
Certification Date: 08/22/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

316 WASHINGTON ST
PROPHETSTOWN IL
61277-1184
US

IV. Provider business mailing address

9660 ALBANY RD
ERIE IL
61250-9721
US

V. Phone/Fax

Practice location:
  • Phone: 815-537-2400
  • Fax:
Mailing address:
  • Phone: 815-590-6506
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number051.302193
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberRPH031626
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: