Provider Demographics
NPI:1336552199
Name:FOX, NICOLE ASHLEY (DPT)
Entity Type:Individual
Prefix:MS
First Name:NICOLE
Middle Name:ASHLEY
Last Name:FOX
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:ASHLEY
Other - Last Name:GREEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DPT
Mailing Address - Street 1:420 N IL ROUTE 31
Mailing Address - Street 2:
Mailing Address - City:CRYSTAL LAKE
Mailing Address - State:IL
Mailing Address - Zip Code:60012-3711
Mailing Address - Country:US
Mailing Address - Phone:815-356-5200
Mailing Address - Fax:815-356-5262
Practice Address - Street 1:420 N IL ROUTE 31
Practice Address - Street 2:
Practice Address - City:CRYSTAL LAKE
Practice Address - State:IL
Practice Address - Zip Code:60012-3711
Practice Address - Country:US
Practice Address - Phone:815-356-5200
Practice Address - Fax:815-356-5262
Is Sole Proprietor?:No
Enumeration Date:2014-06-09
Last Update Date:2018-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist