Provider Demographics
NPI:1255474516
Name:KOONCE, NICOLE MICHELLE
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:MICHELLE
Last Name:KOONCE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:MICHELLE
Other - Last Name:COOKS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1049 EAST WILSON STREET
Mailing Address - Street 2:SUITE 100
Mailing Address - City:BATAVIA
Mailing Address - State:IL
Mailing Address - Zip Code:60510
Mailing Address - Country:US
Mailing Address - Phone:630-761-0900
Mailing Address - Fax:630-761-0909
Practice Address - Street 1:1049 EAST WILSON STREET
Practice Address - Street 2:SUITE 100
Practice Address - City:BATAVIA
Practice Address - State:IL
Practice Address - Zip Code:60510
Practice Address - Country:US
Practice Address - Phone:630-761-0900
Practice Address - Fax:630-761-0909
Is Sole Proprietor?:No
Enumeration Date:2007-02-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist