Provider Demographics
NPI:1689679599
Name:NORRIS, NICOLE EDITH (MD)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:EDITH
Last Name:NORRIS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:600 E 1ST ST
Mailing Address - Street 2:
Mailing Address - City:SPRING VALLEY
Mailing Address - State:IL
Mailing Address - Zip Code:61362-1512
Mailing Address - Country:US
Mailing Address - Phone:815-663-5981
Mailing Address - Fax:815-663-5982
Practice Address - Street 1:600 E 1ST ST
Practice Address - Street 2:
Practice Address - City:SPRING VALLEY
Practice Address - State:IL
Practice Address - Zip Code:61362-1512
Practice Address - Country:US
Practice Address - Phone:815-663-5981
Practice Address - Fax:815-663-5982
Is Sole Proprietor?:No
Enumeration Date:2005-06-16
Last Update Date:2013-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-111100207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036111100Medicaid
ILK09062Medicare ID - Type Unspecified
IL036111100Medicaid