Provider Demographics
NPI:1467916593
Name:GERDEVICH, NICOLE TAYLOR
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:TAYLOR
Last Name:GERDEVICH
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 1:1302 BRANDEN LANE
Mailing Address - Street 2:
Mailing Address - City:BARTLETT
Mailing Address - State:IL
Mailing Address - Zip Code:60103
Mailing Address - Country:US
Mailing Address - Phone:630-450-5201
Mailing Address - Fax:
Practice Address - Street 1:1302 BRANDEN LANE
Practice Address - Street 2:
Practice Address - City:BARTLETT
Practice Address - State:IL
Practice Address - Zip Code:60103
Practice Address - Country:US
Practice Address - Phone:630-450-5201
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-23
Last Update Date:2019-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer