Provider Demographics
NPI:1902315567
Name:MARTY, NICOLE LYNN (MS SLP)
Entity Type:Individual
Prefix:MRS
First Name:NICOLE
Middle Name:LYNN
Last Name:MARTY
Suffix:
Gender:F
Credentials:MS SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:205 S ENGLEWOOD DR
Mailing Address - Street 2:
Mailing Address - City:METAMORA
Mailing Address - State:IL
Mailing Address - Zip Code:61548-8781
Mailing Address - Country:US
Mailing Address - Phone:309-367-4901
Mailing Address - Fax:309-367-4905
Practice Address - Street 1:508 E WALNUT ST
Practice Address - Street 2:
Practice Address - City:WASHBURN
Practice Address - State:IL
Practice Address - Zip Code:61570-7539
Practice Address - Country:US
Practice Address - Phone:309-248-7221
Practice Address - Fax:309-248-7518
Is Sole Proprietor?:No
Enumeration Date:2017-09-27
Last Update Date:2017-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL146006221235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist