Provider Demographics
NPI:1487201877
Name:HEUN, NICOLE R
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:R
Last Name:HEUN
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 1:9660 ALBANY RD
Mailing Address - Street 2:
Mailing Address - City:ERIE
Mailing Address - State:IL
Mailing Address - Zip Code:61250-9721
Mailing Address - Country:US
Mailing Address - Phone:815-590-6506
Mailing Address - Fax:
Practice Address - Street 1:316 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:PROPHETSTOWN
Practice Address - State:IL
Practice Address - Zip Code:61277-1184
Practice Address - Country:US
Practice Address - Phone:815-537-2400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-21
Last Update Date:2023-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051.302193183500000X
GARPH031626183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist