Provider Demographics
NPI:1255440871
Name:NICOLLS, MAUREEN ELIZABETH (MSPT)
Entity type:Individual
Prefix:MRS
First Name:MAUREEN
Middle Name:ELIZABETH
Last Name:NICOLLS
Suffix:
Gender:F
Credentials:MSPT
Other - Prefix:MISS
Other - First Name:MAUREEN
Other - Middle Name:ELIZABETH
Other - Last Name:WOJCIK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 5247
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61125-0247
Mailing Address - Country:US
Mailing Address - Phone:815-398-9491
Mailing Address - Fax:815-381-7498
Practice Address - Street 1:324 ROXBURY RD
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61107-5090
Practice Address - Country:US
Practice Address - Phone:815-398-9491
Practice Address - Fax:815-381-7498
Is Sole Proprietor?:No
Enumeration Date:2006-08-29
Last Update Date:2008-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
206206Medicare ID - Type Unspecified