Provider Demographics
NPI:1073969044
Name:SOPER, NICOLE SUZETTE (APN FNP-BC)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:SUZETTE
Last Name:SOPER
Suffix:
Gender:F
Credentials:APN FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:201 E MADISON ST
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62702-5131
Mailing Address - Country:US
Mailing Address - Phone:217-545-3787
Mailing Address - Fax:217-762-3949
Practice Address - Street 1:302 W HAY ST
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:IL
Practice Address - Zip Code:62526-4167
Practice Address - Country:US
Practice Address - Phone:217-545-8000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-05-10
Last Update Date:2019-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209014230363LF0000X
IL041330758163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse