MEDICARE: JENA C NOWICKI NP-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LF0000X	Family Nurse Practitioner	209017696	IL

General Provider Information

NPI Number	:	1558852699
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JENA C NOWICKI NP-C

Provider Business Mailing Address
First Line	:	5775 E STATE ROUTE 113
Second Line	:
City	:	COAL CITY
State	:	IL
Zip	:	60416-7111
Country	:	US
Telephone Number	:	815-634-0100
Fax Number	:	815-634-2900

Provider Business Practice Location Address
First Line	:	5775 E STATE ROUTE 113
Second Line	:
City	:	COAL CITY
State	:	IL
Zip	:	60416-7111
Country	:	US
Telephone Number	:	815-634-0100
Fax Number	:	815-634-2900

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/24/2018
Last Update Date	:	05/19/2022

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