Provider Demographics
NPI:1881448603
Name:ROUSONELOS, NICOLE NOLA (DAC)
Entity type:Individual
Prefix:DR
First Name:NICOLE
Middle Name:NOLA
Last Name:ROUSONELOS
Suffix:
Gender:F
Credentials:DAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4535 N PAULINA ST APT 2D
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60640-5326
Mailing Address - Country:US
Mailing Address - Phone:815-955-3591
Mailing Address - Fax:
Practice Address - Street 1:1339 W DEVON AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60660-1329
Practice Address - Country:US
Practice Address - Phone:773-293-7642
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-04-17
Last Update Date:2024-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL198.001651171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist