Healthcare Provider Details

I. General information

NPI: 1831427467
Provider Name (Legal Business Name): NICOLE GELLATLY FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/19/2009
Last Update Date: 07/01/2024
Certification Date: 07/01/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1005 BROADWAY ST
QUINCY IL
62301-2834
US

IV. Provider business mailing address

1005 BROADWAY ST
QUINCY IL
62301-2834
US

V. Phone/Fax

Practice location:
  • Phone: 217-223-1200
  • Fax:
Mailing address:
  • Phone: 217-223-1200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberA103901
License Number StateIA
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number209029412
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: