Healthcare Provider Details

I. General information

NPI: 1033392766
Provider Name (Legal Business Name): NICOLE ANANIA D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/17/2007
Last Update Date: 05/29/2024
Certification Date: 05/29/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

250 PARK ST
BOWLING GREEN KY
42101-1795
US

IV. Provider business mailing address

225 E CHICAGO AVE BOX 152
CHICAGO IL
60611-2605
US

V. Phone/Fax

Practice location:
  • Phone: 270-796-5498
  • Fax: 270-796-5490
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number5011
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberR993
License Number StateAZ
# 3
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number036.122521
License Number StateIL
# 4
Primary TaxonomyY
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number05771
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: