Provider Demographics
NPI:1922329507
Name:CHICKRIS-BOLLAERT, NICOLE M (MD)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:M
Last Name:CHICKRIS-BOLLAERT
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 1:525 VALLEY VIEW DR
Mailing Address - Street 2:
Mailing Address - City:MOLINE
Mailing Address - State:IL
Mailing Address - Zip Code:61265-6138
Mailing Address - Country:US
Mailing Address - Phone:309-792-9869
Mailing Address - Fax:309-762-2313
Practice Address - Street 1:5401 44TH AVENUE DR STE 101
Practice Address - Street 2:
Practice Address - City:MOLINE
Practice Address - State:IL
Practice Address - Zip Code:61265-8126
Practice Address - Country:US
Practice Address - Phone:309-779-4050
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-06-17
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036.130996207Q00000X
IL125058663390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1922329507Medicaid
IL036130996Medicaid
IL1922329507Medicaid