Provider Demographics
NPI:1417730938
Name:WAKEFIELD, NICOLE
Entity type:Individual
Prefix:MS
First Name:NICOLE
Middle Name:
Last Name:WAKEFIELD
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:
Other - Last Name:MCCOY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:101 W UNIVERSITY AVE
Mailing Address - Street 2:
Mailing Address - City:CHAMPAIGN
Mailing Address - State:IL
Mailing Address - Zip Code:61820-3909
Mailing Address - Country:US
Mailing Address - Phone:217-366-1255
Mailing Address - Fax:
Practice Address - Street 1:101 W UNIVERSITY AVE
Practice Address - Street 2:
Practice Address - City:CHAMPAIGN
Practice Address - State:IL
Practice Address - Zip Code:61820-3981
Practice Address - Country:US
Practice Address - Phone:217-366-1255
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-17
Last Update Date:2025-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209028120363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner