Provider Demographics
NPI:1952985061
Name:SCHULLO, NICOLE DOMINIQUE
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:DOMINIQUE
Last Name:SCHULLO
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 1:1720 N. LASALLE DRIVE
Mailing Address - Street 2:APT. 20
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60614
Mailing Address - Country:US
Mailing Address - Phone:773-351-0050
Mailing Address - Fax:
Practice Address - Street 1:1330 LINCOLN AVE STE 201
Practice Address - Street 2:
Practice Address - City:SAN RAFAEL
Practice Address - State:CA
Practice Address - Zip Code:94901-2142
Practice Address - Country:US
Practice Address - Phone:415-459-5999
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-06
Last Update Date:2021-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program