MEDICARE: NICOLE LYNNE DAVIS

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	1041C0700X	Clinical Social Worker	149015588	IL

General Provider Information

NPI Number	:	1972086957
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	NICOLE LYNNE DAVIS

Provider Business Mailing Address
First Line	:	1720 S MICHIGAN AVE APT 2804
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60616-4860
Country	:	US
Telephone Number	:	248-320-6435
Fax Number	:

Provider Business Practice Location Address
First Line	:	4507 N RAVENSWOOD AVE STE 111
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60640-5218
Country	:	US
Telephone Number	:	248-320-6435
Fax Number	:

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

Provider Enumeration Date	:	09/14/2018
Last Update Date	:	09/14/2018

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Directions to “ NICOLE LYNNE DAVIS ” Practice Location

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