Provider Demographics
NPI:1073693107
Name:DECKER, NICOLE (OD)
Entity Type:Individual
Prefix:DR
First Name:NICOLE
Middle Name:
Last Name:DECKER
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:360 E RANDOLPH ST APT 3902
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60601-7340
Mailing Address - Country:US
Mailing Address - Phone:708-951-9564
Mailing Address - Fax:
Practice Address - Street 1:360 E RANDOLPH ST APT 3902
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60601-7340
Practice Address - Country:US
Practice Address - Phone:708-951-9564
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-16
Last Update Date:2014-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046009872152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist