Provider Demographics
NPI:1871027151
Name:PINNOCK, NAHSTAJIA NICOLE JOY (MD)
Entity Type:Individual
Prefix:
First Name:NAHSTAJIA
Middle Name:NICOLE JOY
Last Name:PINNOCK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:611 WEST PARK STREET
Mailing Address - Street 2:
Mailing Address - City:CHAMPAIGN
Mailing Address - State:IL
Mailing Address - Zip Code:61822
Mailing Address - Country:US
Mailing Address - Phone:217-363-6792
Mailing Address - Fax:
Practice Address - Street 1:611 WEST PARK STREET
Practice Address - Street 2:
Practice Address - City:CHAMPAIGN
Practice Address - State:IL
Practice Address - Zip Code:61822
Practice Address - Country:US
Practice Address - Phone:217-363-6792
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-13
Last Update Date:2019-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
IL125.074731208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program