Provider Demographics
NPI:1164876967
Name:VENTOCILLA, NICHOLAS K (CRNA)
Entity Type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:K
Last Name:VENTOCILLA
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 836
Mailing Address - Street 2:
Mailing Address - City:CRYSTAL LAKE
Mailing Address - State:IL
Mailing Address - Zip Code:60039-0836
Mailing Address - Country:US
Mailing Address - Phone:847-615-2200
Mailing Address - Fax:
Practice Address - Street 1:875 S ROUTE 31
Practice Address - Street 2:
Practice Address - City:CRYSTAL LAKE
Practice Address - State:IL
Practice Address - Zip Code:60014-8190
Practice Address - Country:US
Practice Address - Phone:779-220-5500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-04-18
Last Update Date:2023-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209014237367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered