Healthcare Provider Details

I. General information

NPI: 1669771861
Provider Name (Legal Business Name): GREGORY ALAN NICHOLS RN, MSN, FNP-BC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/28/2011
Last Update Date: 04/18/2022
Certification Date: 04/18/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 WESTBROOK CORPORATE CTR STE 300
WESTCHESTER IL
60154-5709
US

IV. Provider business mailing address

2115 WATER CHASE DR
NEW LENOX IL
60451-4813
US

V. Phone/Fax

Practice location:
  • Phone: 866-949-0108
  • Fax:
Mailing address:
  • Phone: 815-325-3978
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number209008721
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number209.008721
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: