Provider Demographics
NPI:1386031045
Name:RAVE, NICHOLE CHRISTINE (PA-C)
Entity Type:Individual
Prefix:
First Name:NICHOLE
Middle Name:CHRISTINE
Last Name:RAVE
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:NICHOLE
Other - Middle Name:CHRISTINE
Other - Last Name:SHEEHAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1404 EASTLAND DR STE 204
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:61701-7904
Mailing Address - Country:US
Mailing Address - Phone:309-662-8813
Mailing Address - Fax:309-662-6835
Practice Address - Street 1:1404 EASTLAND DR STE 204
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IL
Practice Address - Zip Code:61701-7904
Practice Address - Country:US
Practice Address - Phone:309-662-8813
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-04-21
Last Update Date:2022-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
2255A2300X, 390200000X
IL085009019207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program