Provider Demographics
NPI:1326341967
Name:ANTHONY, NICOLE ANNETTE
Entity Type:Individual
Prefix:MS
First Name:NICOLE
Middle Name:ANNETTE
Last Name:ANTHONY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2907 WILLIAMSON COUNTY PARKWAY
Mailing Address - Street 2:
Mailing Address - City:MARION
Mailing Address - State:IL
Mailing Address - Zip Code:62959
Mailing Address - Country:US
Mailing Address - Phone:618-998-9894
Mailing Address - Fax:618-998-9993
Practice Address - Street 1:2907 WILLIAMSON COUNTY PARKWAY
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:IL
Practice Address - Zip Code:62959
Practice Address - Country:US
Practice Address - Phone:618-998-9894
Practice Address - Fax:618-998-9993
Is Sole Proprietor?:No
Enumeration Date:2010-12-20
Last Update Date:2021-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL160.005583225200000X
IL070.021876225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant