Provider Demographics
NPI:1710595111
Name:TABATABAI, NICOLE MICHELLE
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:MICHELLE
Last Name:TABATABAI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:345 CLARK DR APT 207
Mailing Address - Street 2:
Mailing Address - City:CORALVILLE
Mailing Address - State:IA
Mailing Address - Zip Code:52241-2435
Mailing Address - Country:US
Mailing Address - Phone:217-622-4976
Mailing Address - Fax:
Practice Address - Street 1:200 HAWKINS DR
Practice Address - Street 2:
Practice Address - City:IOWA CITY
Practice Address - State:IA
Practice Address - Zip Code:52242-1009
Practice Address - Country:US
Practice Address - Phone:217-622-4976
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-21
Last Update Date:2020-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA148315163WC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WC0200XNursing Service ProvidersRegistered NurseCritical Care Medicine