Healthcare Provider Details

I. General information

NPI: 1518239649
Provider Name (Legal Business Name): COURTNEY NICHOLS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/06/2012
Last Update Date: 02/06/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1810 W SOUTH 3RD ST
SHELBYVILLE IL
62565-9595
US

IV. Provider business mailing address

1810 W SOUTH 3RD ST
SHELBYVILLE IL
62565-9595
US

V. Phone/Fax

Practice location:
  • Phone: 217-774-2113
  • Fax:
Mailing address:
  • Phone: 217-774-2113
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License Number043113407
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: