Provider Demographics
NPI:1336675610
Name:DIMARIA, NICHOLE MARIE (FNP)
Entity Type:Individual
Prefix:
First Name:NICHOLE
Middle Name:MARIE
Last Name:DIMARIA
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:NICHOLE
Other - Middle Name:
Other - Last Name:WHATLEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:21202 OWENS RD STE 101
Mailing Address - Street 2:
Mailing Address - City:MOKENA
Mailing Address - State:IL
Mailing Address - Zip Code:60448-2038
Mailing Address - Country:US
Mailing Address - Phone:779-334-0030
Mailing Address - Fax:779-334-0031
Practice Address - Street 1:21202 OWENS RD STE 101
Practice Address - Street 2:
Practice Address - City:MOKENA
Practice Address - State:IL
Practice Address - Zip Code:60448-2038
Practice Address - Country:US
Practice Address - Phone:779-334-0030
Practice Address - Fax:779-334-0031
Is Sole Proprietor?:No
Enumeration Date:2017-05-05
Last Update Date:2022-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209015245363L00000X
IL209.015245363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily