=====================================================
General NPI Number Information
=====================================================
NPI Number | 1326664111
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | NICOLE BRANDI PEDTKE FNP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/17/2020
-----------------------------------------------------
Last Update Date | 06/23/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5680 INDIAN TRAIL RD
-----------------------------------------------------
City | ASHLEY
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 62808-2527
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 618-713-3811
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5680 INDIAN TRAIL RD
-----------------------------------------------------
City | ASHLEY
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 62808-2527
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 618-713-3811
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | 209021411
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------