1255440871 NPI number — MRS. MAUREEN ELIZABETH NICOLLS MSPT

Table of content: MRS. MAUREEN ELIZABETH NICOLLS MSPT (NPI 1255440871)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1255440871 NPI number — MRS. MAUREEN ELIZABETH NICOLLS MSPT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
NICOLLS
Provider First Name:
MAUREEN
Provider Middle Name:
ELIZABETH
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
MSPT
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
WOJCIK
Provider Other First Name:
MAUREEN
Provider Other Middle Name:
ELIZABETH
Provider Other Name Prefix Text:
MISS
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1255440871
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/31/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 5247
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ROCKFORD
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
61125-0247
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
815-398-9491
Provider Business Mailing Address Fax Number:
815-381-7498

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
324 ROXBURY RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ROCKFORD
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
61107-5090
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
815-398-9491
Provider Business Practice Location Address Fax Number:
815-381-7498
Provider Enumeration Date:
08/29/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)