Basic Information
Provider Information | |||||||||
NPI: | 1174776843 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | PAULEY | ||||||||
FirstName: | NICHOLE | ||||||||
MiddleName: | C | ||||||||
NamePrefix: | MS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | CST/CSFA | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | LAPPIN | ||||||||
OtherFirstName: | NICHOLE | ||||||||
OtherMiddleName: | C | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 1604 VISA DR. | ||||||||
Address2: | STE. 1 | ||||||||
City: | NORMAL | ||||||||
State: | IL | ||||||||
PostalCode: | 61761 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3098464716 | ||||||||
FaxNumber: | 3094547348 | ||||||||
Practice Location | |||||||||
Address1: | 1604 VISA DR. | ||||||||
Address2: | STE. 1 | ||||||||
City: | NORMAL | ||||||||
State: | IL | ||||||||
PostalCode: | 61761 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3098464716 | ||||||||
FaxNumber: | 3094547348 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/28/2008 | ||||||||
LastUpdateDate: | 03/03/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 03/03/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 246ZS0410X | 238.000120 | IL | N |   |   |   |   | 246ZC0007X | 238.000.120 | IL | Y |   | Technologists, Technicians & Other Technical Service Providers | Specialist/Technologist, Other | Certified First Assistant |
No ID Information.