Provider Demographics
NPI:1578049029
Name:ILLICHMANN, NADINE M (DC)
Entity Type:Individual
Prefix:
First Name:NADINE
Middle Name:M
Last Name:ILLICHMANN
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1239 W MASON ST
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54303-2047
Mailing Address - Country:US
Mailing Address - Phone:920-884-6100
Mailing Address - Fax:
Practice Address - Street 1:1239 W MASON ST
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54303-2047
Practice Address - Country:US
Practice Address - Phone:920-884-6100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-18
Last Update Date:2018-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5374-12111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor