Provider Demographics
NPI:1730212309
Name:NETTGEN, NICOLE S (CNM)
Entity type:Individual
Prefix:MS
First Name:NICOLE
Middle Name:S
Last Name:NETTGEN
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1007 LARK LN
Mailing Address - Street 2:
Mailing Address - City:SHOREWOOD
Mailing Address - State:IL
Mailing Address - Zip Code:60404-9649
Mailing Address - Country:US
Mailing Address - Phone:815-933-4510
Mailing Address - Fax:815-933-4259
Practice Address - Street 1:375 N WALL ST
Practice Address - Street 2:SUITE P630
Practice Address - City:KANKAKEE
Practice Address - State:IL
Practice Address - Zip Code:60901-3483
Practice Address - Country:US
Practice Address - Phone:815-933-4510
Practice Address - Fax:815-933-4259
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-13
Last Update Date:2017-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209-003302367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife