Basic Information
| Provider Information | |||||||||
| NPI: | 1205429503 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | NICHOLSON | ||||||||
| FirstName: | HALEIGH | ||||||||
| MiddleName: | RANAE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 615 S OAKWOOD ST | ||||||||
| Address2: | |||||||||
| City: | OAKWOOD | ||||||||
| State: | IL | ||||||||
| PostalCode: | 618589571 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2174746165 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3653 N. VERMILION STREET | ||||||||
| Address2: | |||||||||
| City: | DANVILLE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 61832 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2175546827 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/17/2021 | ||||||||
| LastUpdateDate: | 03/11/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/18/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 209022381 | IL | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.