Provider Demographics
NPI:1588239784
Name:GONZALES, NIKKO D
Entity Type:Individual
Prefix:
First Name:NIKKO
Middle Name:D
Last Name:GONZALES
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 1:5421 S 74TH AVE
Mailing Address - Street 2:
Mailing Address - City:SUMMIT
Mailing Address - State:IL
Mailing Address - Zip Code:60501-1016
Mailing Address - Country:US
Mailing Address - Phone:929-218-2723
Mailing Address - Fax:
Practice Address - Street 1:1035 MADISON ST
Practice Address - Street 2:
Practice Address - City:OAK PARK
Practice Address - State:IL
Practice Address - Zip Code:60302-4449
Practice Address - Country:US
Practice Address - Phone:708-725-1081
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-21
Last Update Date:2021-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070023488225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist