MEDICARE: NICOLE MARIE CHUM FNP-BC

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	209.025606	IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	209.025606	OTHER	IL	STATE OF ILLINOIS APRN LICENSE

General Provider Information

NPI Number	:	1699402016
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	NICOLE MARIE CHUM FNP-BC

Provider Business Mailing Address
First Line	:	1986 N 2919TH RD
Second Line	:
City	:	MARSEILLES
State	:	IL
Zip	:	61341-9002
Country	:	US
Telephone Number	:	815-343-4494
Fax Number	:

Provider Business Practice Location Address
First Line	:	920 WEST ST STE 216
Second Line	:
City	:	PERU
State	:	IL
Zip	:	61354-2769
Country	:	US
Telephone Number	:	309-451-3376
Fax Number	:	309-452-3376

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

Provider Enumeration Date	:	08/05/2022
Last Update Date	:	08/05/2022

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