Provider Demographics
NPI:1629046099
Name:PAUTZ, NICOLE RENEE (ATC)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:RENEE
Last Name:PAUTZ
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3616 W WILSON AVE
Mailing Address - Street 2:UNIT 1
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60625-5822
Mailing Address - Country:US
Mailing Address - Phone:773-267-0287
Mailing Address - Fax:
Practice Address - Street 1:3233 W ADDISON ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60618-4328
Practice Address - Country:US
Practice Address - Phone:773-478-0496
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-10
Last Update Date:2008-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL96-0012282255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer