Provider Demographics
NPI:1548611130
Name:WEYDERT, NICOLE
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:WEYDERT
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 1:2096 SAND HILL CT
Mailing Address - Street 2:
Mailing Address - City:MONTGOMERY
Mailing Address - State:IL
Mailing Address - Zip Code:60538-6000
Mailing Address - Country:US
Mailing Address - Phone:630-527-9100
Mailing Address - Fax:
Practice Address - Street 1:1250 S NAPER BLVD
Practice Address - Street 2:
Practice Address - City:NAPERVILLE
Practice Address - State:IL
Practice Address - Zip Code:60540-8312
Practice Address - Country:US
Practice Address - Phone:630-527-9100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-25
Last Update Date:2016-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL227013408225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist