Provider Demographics
NPI:1619212107
Name:HAUBRICH, NICOLLETTE M (FNP-BC)
Entity Type:Individual
Prefix:
First Name:NICOLLETTE
Middle Name:M
Last Name:HAUBRICH
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:927 BROADWAY ST
Mailing Address - Street 2:STE 101
Mailing Address - City:QUINCY
Mailing Address - State:IL
Mailing Address - Zip Code:62301-2719
Mailing Address - Country:US
Mailing Address - Phone:217-214-5660
Mailing Address - Fax:217-214-5678
Practice Address - Street 1:927 BROADWAY ST
Practice Address - Street 2:STE 101
Practice Address - City:QUINCY
Practice Address - State:IL
Practice Address - Zip Code:62301-2719
Practice Address - Country:US
Practice Address - Phone:217-214-5660
Practice Address - Fax:217-214-5678
Is Sole Proprietor?:No
Enumeration Date:2012-12-10
Last Update Date:2013-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209-009999363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL$$$$$$$$$001Medicaid
IL522000024Medicare PIN