Provider Demographics
NPI:1093363517
Name:FITCH, NICOLE MARIE
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:MARIE
Last Name:FITCH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:403 VANCE DR
Mailing Address - Street 2:
Mailing Address - City:OLNEY
Mailing Address - State:IL
Mailing Address - Zip Code:62450-2423
Mailing Address - Country:US
Mailing Address - Phone:618-553-7436
Mailing Address - Fax:
Practice Address - Street 1:111 W. MOUND ST.
Practice Address - Street 2:
Practice Address - City:STE. MARIE
Practice Address - State:IL
Practice Address - Zip Code:62459-0185
Practice Address - Country:US
Practice Address - Phone:618-455-3396
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-28
Last Update Date:2019-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist