Provider Demographics
NPI:1548719487
Name:MADDOCK, NICOLE
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:MADDOCK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:319 W LORAIN ST
Mailing Address - Street 2:
Mailing Address - City:OBERLIN
Mailing Address - State:OH
Mailing Address - Zip Code:44074-1027
Mailing Address - Country:US
Mailing Address - Phone:440-775-1881
Mailing Address - Fax:440-774-5707
Practice Address - Street 1:319 W LORAIN ST
Practice Address - Street 2:
Practice Address - City:OBERLIN
Practice Address - State:OH
Practice Address - Zip Code:44074-1027
Practice Address - Country:US
Practice Address - Phone:440-775-1881
Practice Address - Fax:440-774-5707
Is Sole Proprietor?:No
Enumeration Date:2016-10-03
Last Update Date:2016-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHAPRN.CNP.019975363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHH519530Medicare PIN
OHH519531Medicare PIN
OHH519532Medicare PIN