Provider Demographics
NPI:1528615168
Name:PICENO, NANCY S (OD)
Entity type:Individual
Prefix:
First Name:NANCY
Middle Name:S
Last Name:PICENO
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1360 N SANDBURG TER APT 1610C
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60610-7902
Mailing Address - Country:US
Mailing Address - Phone:626-353-2710
Mailing Address - Fax:
Practice Address - Street 1:4741 W CERMAK RD
Practice Address - Street 2:
Practice Address - City:CICERO
Practice Address - State:IL
Practice Address - Zip Code:60804-2508
Practice Address - Country:US
Practice Address - Phone:708-391-1763
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-19
Last Update Date:2019-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046011366152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist