Provider Demographics
NPI:1770974800
Name:THOMAS, NICOLE (FNP)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:THOMAS
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1437 E COLLEGE AVE
Mailing Address - Street 2:
Mailing Address - City:NORMAL
Mailing Address - State:IL
Mailing Address - Zip Code:61761-2085
Mailing Address - Country:US
Mailing Address - Phone:309-862-5700
Mailing Address - Fax:309-862-5705
Practice Address - Street 1:1437 E COLLEGE AVE
Practice Address - Street 2:
Practice Address - City:NORMAL
Practice Address - State:IL
Practice Address - Zip Code:61761-2085
Practice Address - Country:US
Practice Address - Phone:309-862-5700
Practice Address - Fax:309-862-5705
Is Sole Proprietor?:No
Enumeration Date:2015-02-11
Last Update Date:2024-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209012492363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL2014026661OtherANCC CERTIFICATION