Provider Demographics
NPI:1093992539
Name:WILLIS, NICOLE (DC)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:WILLIS
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:DAWN
Other - Middle Name:NICOLE
Other - Last Name:WILLIS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DC
Mailing Address - Street 1:1570 E HERITAGE PARK ST
Mailing Address - Street 2:STE 175
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83646-6445
Mailing Address - Country:US
Mailing Address - Phone:208-322-4114
Mailing Address - Fax:208-322-4115
Practice Address - Street 1:1570 E HERITAGE PARK ST
Practice Address - Street 2:STE 175
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83646-6445
Practice Address - Country:US
Practice Address - Phone:208-322-4114
Practice Address - Fax:208-322-4115
Is Sole Proprietor?:No
Enumeration Date:2008-01-28
Last Update Date:2020-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDCHIA-1268111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
1370103OtherGROUP PTAN