Provider Demographics
NPI:1679952956
Name:DUVALL, NICOLE LYNN (LMT, NCBTMB)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:LYNN
Last Name:DUVALL
Suffix:
Gender:F
Credentials:LMT, NCBTMB
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:640 W SOUTH ST
Mailing Address - Street 2:
Mailing Address - City:FREEPORT
Mailing Address - State:IL
Mailing Address - Zip Code:61032-6838
Mailing Address - Country:US
Mailing Address - Phone:815-235-2301
Mailing Address - Fax:
Practice Address - Street 1:640 W SOUTH ST
Practice Address - Street 2:
Practice Address - City:FREEPORT
Practice Address - State:IL
Practice Address - Zip Code:61032-6838
Practice Address - Country:US
Practice Address - Phone:815-235-2301
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-05-20
Last Update Date:2020-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL227.011956175L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175L00000XOther Service ProvidersHomeopath