Provider Demographics
NPI:1386418929
Name:FANUCCHI, NICOLE
Entity type:Individual
Prefix:MRS
First Name:NICOLE
Middle Name:
Last Name:FANUCCHI
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 1:163 WINDING HILL DR
Mailing Address - Street 2:
Mailing Address - City:ELGIN
Mailing Address - State:IL
Mailing Address - Zip Code:60124-0202
Mailing Address - Country:US
Mailing Address - Phone:773-412-3706
Mailing Address - Fax:
Practice Address - Street 1:163 WINDING HILL DR
Practice Address - Street 2:
Practice Address - City:ELGIN
Practice Address - State:IL
Practice Address - Zip Code:60124-0202
Practice Address - Country:US
Practice Address - Phone:773-412-3706
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-11-14
Last Update Date:2023-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL041456615163WA0400X, 163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WA0400XNursing Service ProvidersRegistered NurseAddiction (Substance Use Disorder)
No163W00000XNursing Service ProvidersRegistered Nurse