Basic Information
| Provider Information | |||||||||
| NPI: | 1720203789 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DOOLEY | ||||||||
| FirstName: | NICKOLE | ||||||||
| MiddleName: | A. | ||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2650 RIDGE AVE | ||||||||
| Address2: | EVANSTON HOSPITAL | ||||||||
| City: | EVANSTON | ||||||||
| State: | IL | ||||||||
| PostalCode: | 602011718 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8475701206 | ||||||||
| FaxNumber: | 8475701248 | ||||||||
| Practice Location | |||||||||
| Address1: | 103 S GREENLEAF ST | ||||||||
| Address2: | SUITE J | ||||||||
| City: | GURNEE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600313380 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8475998899 | ||||||||
| FaxNumber: | 8475998897 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/16/2007 | ||||||||
| LastUpdateDate: | 02/10/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/10/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 036-116737 | IL | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 036-116737 | 01 | IL | IL STATE LIC | OTHER |