Provider Demographics
NPI:1649749664
Name:WODKA, NICOLE F (DPT)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:F
Last Name:WODKA
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1962 N BISSELL ST UNIT 1
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60614-5015
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1962 N BISSELL ST UNIT 1
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60614-5015
Practice Address - Country:US
Practice Address - Phone:312-598-9991
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-11-20
Last Update Date:2020-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070022654225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist