Provider Demographics
NPI:1356684823
Name:HARRISON, NICOLE MICHELLE (LPN)
Entity Type:Individual
Prefix:MRS
First Name:NICOLE
Middle Name:MICHELLE
Last Name:HARRISON
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:534 LUELLA AVE
Mailing Address - Street 2:
Mailing Address - City:CALUMET CITY
Mailing Address - State:IL
Mailing Address - Zip Code:60409-3102
Mailing Address - Country:US
Mailing Address - Phone:708-715-3534
Mailing Address - Fax:
Practice Address - Street 1:534 LUELLA AVE
Practice Address - Street 2:
Practice Address - City:CALUMET CITY
Practice Address - State:IL
Practice Address - Zip Code:60409-3102
Practice Address - Country:US
Practice Address - Phone:708-715-3534
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-02
Last Update Date:2013-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL043106314164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse