Provider Demographics
NPI:1770770133
Name:TURNER, NICKY R (FNP)
Entity type:Individual
Prefix:
First Name:NICKY
Middle Name:R
Last Name:TURNER
Suffix:
Gender:M
Credentials:FNP
Other - Prefix:
Other - First Name:NICK
Other - Middle Name:
Other - Last Name:TURNER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:FNP
Mailing Address - Street 1:200 SUSANN DR
Mailing Address - Street 2:
Mailing Address - City:WEST FRANKFORT
Mailing Address - State:IL
Mailing Address - Zip Code:62896-1937
Mailing Address - Country:US
Mailing Address - Phone:618-967-3166
Mailing Address - Fax:
Practice Address - Street 1:1012 BELMONT AVE
Practice Address - Street 2:
Practice Address - City:LA JUNTA
Practice Address - State:CO
Practice Address - Zip Code:81050-2101
Practice Address - Country:US
Practice Address - Phone:719-383-5500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-10-01
Last Update Date:2020-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209006768363L00000X
COAPN.0995881-NP363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL370966854023Medicaid
IL370966854023Medicaid
IL141106Medicare Oscar/Certification
IL640701Medicare Oscar/Certification
IL141106Medicare Oscar/Certification
IL209006768Medicaid
IL214881Medicare Oscar/Certification