Basic Information
| Provider Information | |||||||||
| NPI: | 1457791741 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PADILLA | ||||||||
| FirstName: | NICOLE | ||||||||
| MiddleName: | MARIE | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 360 STATION DR | ||||||||
| Address2: | |||||||||
| City: | CRYSTAL LAKE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600147978 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8153386600 | ||||||||
| FaxNumber: | 8154265162 | ||||||||
| Practice Location | |||||||||
| Address1: | 1925 HUNTLEY RD | ||||||||
| Address2: | |||||||||
| City: | WEST DUNDEE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 60118 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8153386600 | ||||||||
| FaxNumber: | 8474265162 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/01/2013 | ||||||||
| LastUpdateDate: | 10/28/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 10/28/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 125064024 | IL | N | Allopathic & Osteopathic Physicians | Family Medicine | 208M00000X | 036140735 | IL | N | Allopathic & Osteopathic Physicians | Hospitalist | 207Q00000X | 036140735 | IL | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 036140735 | 01 | IL | STATE LICENSE | OTHER |