Basic Information
| Provider Information | |||||||||
| NPI: | 1326109992 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DALTON | ||||||||
| FirstName: | NICOLE | ||||||||
| MiddleName: | |||||||||
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| Credential: | P.A. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2300 N EDWARD ST | ||||||||
| Address2: | |||||||||
| City: | DECATUR | ||||||||
| State: | IL | ||||||||
| PostalCode: | 625264163 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2178762868 | ||||||||
| FaxNumber: | 2178762874 | ||||||||
| Practice Location | |||||||||
| Address1: | 241 W WEAVER RD | ||||||||
| Address2: | SUITE 145B | ||||||||
| City: | FORSYTH | ||||||||
| State: | IL | ||||||||
| PostalCode: | 625359762 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2177945472 | ||||||||
| FaxNumber: | 2177945458 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/13/2006 | ||||||||
| LastUpdateDate: | 04/28/2010 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 085-001647 | IL | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 833120 | 01 | MEDICARE GROUP # | OTHER | P00807365 | 01 | RR INDIVIDUAL # | OTHER | CA2264 | 01 | RR GROUP # | OTHER |