Provider Demographics
NPI:1649794942
Name:NICHOLS-BREER, NICOLE RENEE
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:RENEE
Last Name:NICHOLS-BREER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:626 N 2375 EAST RD
Mailing Address - Street 2:
Mailing Address - City:MODE
Mailing Address - State:IL
Mailing Address - Zip Code:62444-4039
Mailing Address - Country:US
Mailing Address - Phone:217-690-2983
Mailing Address - Fax:
Practice Address - Street 1:1111 W NORTH 12TH ST
Practice Address - Street 2:
Practice Address - City:SHELBYVILLE
Practice Address - State:IL
Practice Address - Zip Code:62565-9554
Practice Address - Country:US
Practice Address - Phone:217-774-2111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-07-28
Last Update Date:2017-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant