Provider Demographics
NPI:1821637927
Name:RHOADES, NICKOLAS ALLEN
Entity Type:Individual
Prefix:
First Name:NICKOLAS
Middle Name:ALLEN
Last Name:RHOADES
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:404 WATFORD DR
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:61704-1203
Mailing Address - Country:US
Mailing Address - Phone:309-242-8747
Mailing Address - Fax:
Practice Address - Street 1:2406 E EMPIRE ST
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IL
Practice Address - Zip Code:61704-3630
Practice Address - Country:US
Practice Address - Phone:309-662-4321
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-06
Last Update Date:2020-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209020288363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner