Provider Demographics
NPI:1134643661
Name:KOENEN, NICOLE CHAO (CPNP-PC)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:CHAO
Last Name:KOENEN
Suffix:
Gender:F
Credentials:CPNP-PC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1130 S MICHIGAN AVE APT 3516
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60605-2323
Mailing Address - Country:US
Mailing Address - Phone:510-386-1296
Mailing Address - Fax:
Practice Address - Street 1:7447 W TALCOTT AVE STE 561
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60631-3716
Practice Address - Country:US
Practice Address - Phone:773-467-8866
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-07-26
Last Update Date:2017-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP134352363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics