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General NPI Number Information
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NPI Number | 1902487689
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Entity Type | Individual
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Provider Name | MELISSA ASHLEY NICKLES
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Gender | Female
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Dates
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Enumeration Date | 04/15/2021
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Last Update Date | 08/02/2024
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Provider Practice Location Address
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Address Line | 808 S WOOD ST # 3E
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City | CHICAGO
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State | IL
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Zip | 60612-7300
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Country | US
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Telephone | 312-996-8666
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Fax |
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Provider Business Mailing Address
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Address Line | 1853 W POLK ST # MC785
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City | CHICAGO
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State | IL
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Zip | 60612-4355
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Country | US
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Telephone | 847-271-1976
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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 | 207R00000X
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Taxonomy Name | Internal Medicine Physician
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License Number | 125.079601
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License Number State | IL
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Taxonomy #2
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Taxonomy Code | 207N00000X
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Taxonomy Name | Dermatology Physician
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License Number | 125.079601
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License Number State | IL
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