Provider Demographics
NPI:1821548207
Name:VETTER, NICOLE (APN)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:VETTER
Suffix:
Gender:F
Credentials:APN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2 GOOD SAMARITAN WAY
Mailing Address - Street 2:MEDICAL PLAZA SUITE 420
Mailing Address - City:MOUNT VERNON
Mailing Address - State:IL
Mailing Address - Zip Code:62864-2408
Mailing Address - Country:US
Mailing Address - Phone:618-899-4000
Mailing Address - Fax:618-899-4790
Practice Address - Street 1:2 GOOD SAMARITAN WAY
Practice Address - Street 2:MEDICAL PLAZA SUITE 420
Practice Address - City:MOUNT VERNON
Practice Address - State:IL
Practice Address - Zip Code:62864-2408
Practice Address - Country:US
Practice Address - Phone:618-899-4000
Practice Address - Fax:618-899-4790
Is Sole Proprietor?:No
Enumeration Date:2016-10-10
Last Update Date:2020-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209014929363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily