Provider Demographics
NPI:1083127104
Name:HAVEL, NICOLE MARIE (ATC)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:MARIE
Last Name:HAVEL
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:203 ERIC AVE
Mailing Address - Street 2:
Mailing Address - City:MT PROSPECT
Mailing Address - State:IL
Mailing Address - Zip Code:60056-2690
Mailing Address - Country:US
Mailing Address - Phone:847-494-6409
Mailing Address - Fax:
Practice Address - Street 1:2240 BUCHTEL BLVD
Practice Address - Street 2:
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80210-3447
Practice Address - Country:US
Practice Address - Phone:847-494-6409
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-11-11
Last Update Date:2017-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA20000290482083S0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2083S0010XAllopathic & Osteopathic PhysiciansPreventive MedicineSports Medicine