Provider Demographics
NPI:1831564848
Name:THERIAULT, NATALIE (MS, FNP-BC)
Entity type:Individual
Prefix:MRS
First Name:NATALIE
Middle Name:
Last Name:THERIAULT
Suffix:
Gender:F
Credentials:MS, FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1765 N ELSTON AVE
Mailing Address - Street 2:SUITE 110
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60642-1501
Mailing Address - Country:US
Mailing Address - Phone:773-276-1100
Mailing Address - Fax:773-276-1102
Practice Address - Street 1:1765 N ELSTON AVE
Practice Address - Street 2:SUITE 110
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60642-1501
Practice Address - Country:US
Practice Address - Phone:773-276-1100
Practice Address - Fax:773-276-1102
Is Sole Proprietor?:No
Enumeration Date:2015-12-02
Last Update Date:2015-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209013636363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily