Provider Demographics
NPI:1568659423
Name:VILLARREAL, NICOLE DAWN (MD)
Entity Type:Individual
Prefix:DR
First Name:NICOLE
Middle Name:DAWN
Last Name:VILLARREAL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16856 OAK VALLEY RD
Mailing Address - Street 2:
Mailing Address - City:CRESCENT
Mailing Address - State:IA
Mailing Address - Zip Code:51526-4226
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:16856 OAK VALLEY RD
Practice Address - Street 2:
Practice Address - City:CRESCENT
Practice Address - State:IA
Practice Address - Zip Code:51526-4226
Practice Address - Country:US
Practice Address - Phone:712-545-9075
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-09-25
Last Update Date:2015-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD28338208000000X
WAMD600090646208000000X
IA39803208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE47068731712Medicaid
IA058970022Medicare PIN
IA1568659423Medicaid