Provider Demographics
NPI:1760559207
Name:NOUWAIRI, NICOLE SORAYA (CRNA)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:SORAYA
Last Name:NOUWAIRI
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2202 HARLEM ROAD
Mailing Address - Street 2:
Mailing Address - City:LOVES PARK
Mailing Address - State:IL
Mailing Address - Zip Code:61111-2754
Mailing Address - Country:US
Mailing Address - Phone:815-877-4848
Mailing Address - Fax:815-636-6125
Practice Address - Street 1:2202 HARLEM ROAD
Practice Address - Street 2:
Practice Address - City:LOVES PARK
Practice Address - State:IL
Practice Address - Zip Code:61111-2754
Practice Address - Country:US
Practice Address - Phone:815-877-4848
Practice Address - Fax:815-636-6125
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-29
Last Update Date:2019-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209013378367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX85154UOtherBLUE CROSS PROVIDER ID
TX173674601Medicaid
P00225343OtherRAILROAD MEDICARE
P00225343Medicare PIN
8D5810Medicare PIN