Provider Demographics
NPI:1457791741
Name:PADILLA, NICOLE MARIE (MD)
Entity Type:Individual
Prefix:MS
First Name:NICOLE
Middle Name:MARIE
Last Name:PADILLA
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 1:360 STATION DR
Mailing Address - Street 2:
Mailing Address - City:CRYSTAL LAKE
Mailing Address - State:IL
Mailing Address - Zip Code:60014-7978
Mailing Address - Country:US
Mailing Address - Phone:815-338-6600
Mailing Address - Fax:815-426-5162
Practice Address - Street 1:1925 HUNTLEY RD
Practice Address - Street 2:
Practice Address - City:WEST DUNDEE
Practice Address - State:IL
Practice Address - Zip Code:60118
Practice Address - Country:US
Practice Address - Phone:815-338-6600
Practice Address - Fax:847-426-5162
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-01
Last Update Date:2021-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL125064024207Q00000X
IL036140735208M00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036140735OtherSTATE LICENSE