Provider Demographics
NPI:1124412374
Name:NICOL, LARA KATHRYN (MD)
Entity Type:Individual
Prefix:
First Name:LARA
Middle Name:KATHRYN
Last Name:NICOL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2511 N KEDZIE BLVD
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60647-2603
Mailing Address - Country:US
Mailing Address - Phone:773-292-2700
Mailing Address - Fax:
Practice Address - Street 1:4211 N CICERO AVE STE 308
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60641-1649
Practice Address - Country:US
Practice Address - Phone:773-736-6125
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-03-26
Last Update Date:2021-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-122174207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine