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General NPI Number Information
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NPI Number | 1184989964
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Entity Type | Individual
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Provider Name | DEBRA RENAE NICKOLI PT
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Gender | Female
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Dates
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Enumeration Date | 07/09/2012
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Last Update Date | 07/09/2012
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Provider Practice Location Address
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Address Line | 401 E ONTARIO ST APT 4003
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City | CHICAGO
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State | IL
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Zip | 60611-4443
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Country | US
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Telephone | 614-668-6237
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Fax |
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Provider Business Mailing Address
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Address Line | 401 E ONTARIO ST APT 4003
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City | CHICAGO
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State | IL
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Zip | 60611-4443
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Country | US
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Telephone | 614-668-6237
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2251P0200X
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Taxonomy Name | Pediatric Physical Therapist
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License Number | 070018390
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License Number State | IL
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