Provider Demographics
NPI:1710261938
Name:RISSMAN, NICOLE RENEE (FNP-C)
Entity Type:Individual
Prefix:MRS
First Name:NICOLE
Middle Name:RENEE
Last Name:RISSMAN
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:230 MILBRIDGE DR
Mailing Address - Street 2:
Mailing Address - City:SYCAMORE
Mailing Address - State:IL
Mailing Address - Zip Code:60178-8868
Mailing Address - Country:US
Mailing Address - Phone:815-739-7811
Mailing Address - Fax:
Practice Address - Street 1:25 N. WINFIELD RD.
Practice Address - Street 2:
Practice Address - City:WINFIELD
Practice Address - State:IL
Practice Address - Zip Code:60190-1295
Practice Address - Country:US
Practice Address - Phone:630-933-2113
Practice Address - Fax:630-933-4520
Is Sole Proprietor?:No
Enumeration Date:2011-10-06
Last Update Date:2012-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209.008894363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL206147OtherMEDICARE PTAN (GROUP)
IL206147096OtherMEDICARE PTAN (INDIVIDUAL)
IL$$$$$$$$$001Medicaid