Provider Demographics
NPI:1184022576
Name:WARREN, NICOLE (PA-C)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:WARREN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:KIRSTINE
Other - Last Name:BAIR
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:25 N WINFIELD RD STE 2202
Mailing Address - Street 2:
Mailing Address - City:WINFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:60190-1379
Mailing Address - Country:US
Mailing Address - Phone:630-352-5450
Mailing Address - Fax:630-352-4320
Practice Address - Street 1:25 N WINFIELD RD STE 2202
Practice Address - Street 2:
Practice Address - City:WINFIELD
Practice Address - State:IL
Practice Address - Zip Code:60190-1379
Practice Address - Country:US
Practice Address - Phone:630-352-5450
Practice Address - Fax:630-352-4320
Is Sole Proprietor?:No
Enumeration Date:2014-12-17
Last Update Date:2024-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085009526363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant