Provider Demographics
NPI:1386244358
Name:ERHARDT, NICHOLE
Entity type:Individual
Prefix:
First Name:NICHOLE
Middle Name:
Last Name:ERHARDT
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 1:8615 COUNTRY SHIRE LN
Mailing Address - Street 2:
Mailing Address - City:SPRING GROVE
Mailing Address - State:IL
Mailing Address - Zip Code:60081-8990
Mailing Address - Country:US
Mailing Address - Phone:847-732-1328
Mailing Address - Fax:
Practice Address - Street 1:390 E CONGRESS PKWY STE I
Practice Address - Street 2:
Practice Address - City:CRYSTAL LAKE
Practice Address - State:IL
Practice Address - Zip Code:60014-6207
Practice Address - Country:US
Practice Address - Phone:815-355-1605
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-29
Last Update Date:2024-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209022284363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner