Provider Demographics
NPI:1851089643
Name:NICHOLSON-SMITH, KIMBERLY LISA (AUD)
Entity Type:Individual
Prefix:MRS
First Name:KIMBERLY
Middle Name:LISA
Last Name:NICHOLSON-SMITH
Suffix:
Gender:F
Credentials:AUD
Other - Prefix:
Other - First Name:KIMBERLY
Other - Middle Name:LISA
Other - Last Name:NICHOLSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1201 EAGLE STREET JOLIET VA CLINIC
Mailing Address - Street 2:
Mailing Address - City:JOILET
Mailing Address - State:IL
Mailing Address - Zip Code:60432
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1201 EAGLE STREET JOLIET VA CLINIC
Practice Address - Street 2:
Practice Address - City:JOILET
Practice Address - State:IL
Practice Address - Zip Code:60432
Practice Address - Country:US
Practice Address - Phone:815-740-8100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-04-28
Last Update Date:2023-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL147.001881231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist