Provider Demographics
NPI:1407988454
Name:NILLES, LAURA (PT)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:
Last Name:NILLES
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1508 HYDE PARK LN
Mailing Address - Street 2:
Mailing Address - City:NAPERVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60565-1621
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2940 ROLLINGRIDGE RD
Practice Address - Street 2:SUITE 100
Practice Address - City:NAPERVILLE
Practice Address - State:IL
Practice Address - Zip Code:60564-4231
Practice Address - Country:US
Practice Address - Phone:630-369-4771
Practice Address - Fax:630-369-6127
Is Sole Proprietor?:No
Enumeration Date:2007-03-12
Last Update Date:2008-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILK46374Medicare PIN
ILP00439239Medicare PIN