Provider Demographics
NPI:1003837725
Name:HAMPTON, NICHELLE R (DO)
Entity Type:Individual
Prefix:
First Name:NICHELLE
Middle Name:R
Last Name:HAMPTON
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21200 S LAGRANGE RD
Mailing Address - Street 2:SUITE 305
Mailing Address - City:FRANKFORT
Mailing Address - State:IL
Mailing Address - Zip Code:60423-2003
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:21200 S LAGRANGE RD
Practice Address - Street 2:SUITE 305
Practice Address - City:FRANKFORT
Practice Address - State:IL
Practice Address - Zip Code:60423-2003
Practice Address - Country:US
Practice Address - Phone:815-406-5011
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-21
Last Update Date:2014-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-096408207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILH25525Medicare UPIN