Provider Demographics
NPI:1467110361
Name:NOLAN, TINA
Entity Type:Individual
Prefix:
First Name:TINA
Middle Name:
Last Name:NOLAN
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 1:24813 S MCCORMICK WAY
Mailing Address - Street 2:
Mailing Address - City:MANHATTAN
Mailing Address - State:IL
Mailing Address - Zip Code:60442-7768
Mailing Address - Country:US
Mailing Address - Phone:815-954-1634
Mailing Address - Fax:
Practice Address - Street 1:24813 S MCCORMICK WAY
Practice Address - Street 2:
Practice Address - City:MANHATTAN
Practice Address - State:IL
Practice Address - Zip Code:60442-7768
Practice Address - Country:US
Practice Address - Phone:815-954-1634
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-12-08
Last Update Date:2021-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ILB55081371913172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver