=====================================================
General NPI Number Information
=====================================================
NPI Number | 1871735290
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | NICHOLE ELIZABETH WIEPERT M.D.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/31/2009
-----------------------------------------------------
Last Update Date | 06/06/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1850 GATEWAY DR STE 201
-----------------------------------------------------
City | SYCAMORE
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60178-3192
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 815-766-7021
-----------------------------------------------------
Fax | 815-758-5690
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1850 GATEWAY DR STE 201
-----------------------------------------------------
City | SYCAMORE
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60178-3192
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 815-766-7021
-----------------------------------------------------
Fax | 815-758-5690
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207V00000X
-----------------------------------------------------
Taxonomy Name | Obstetrics & Gynecology Physician
-----------------------------------------------------
License Number | 036132373
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------