Healthcare Provider Details

I. General information

NPI: 1649794942
Provider Name (Legal Business Name): NICOLE RENEE NICHOLS-BREER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/28/2017
Last Update Date: 07/28/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1111 W NORTH 12TH ST
SHELBYVILLE IL
62565-9554
US

IV. Provider business mailing address

626 N 2375 EAST RD
MODE IL
62444-4039
US

V. Phone/Fax

Practice location:
  • Phone: 217-774-2111
  • Fax:
Mailing address:
  • Phone: 217-690-2983
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: