Provider Demographics
NPI:1699402016
Name:CHUM, NICOLE MARIE (FNP-BC)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:MARIE
Last Name:CHUM
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1986 N 2919TH RD
Mailing Address - Street 2:
Mailing Address - City:MARSEILLES
Mailing Address - State:IL
Mailing Address - Zip Code:61341-9002
Mailing Address - Country:US
Mailing Address - Phone:815-343-4494
Mailing Address - Fax:
Practice Address - Street 1:920 WEST ST STE 216
Practice Address - Street 2:
Practice Address - City:PERU
Practice Address - State:IL
Practice Address - Zip Code:61354-2769
Practice Address - Country:US
Practice Address - Phone:309-451-3376
Practice Address - Fax:309-452-3376
Is Sole Proprietor?:No
Enumeration Date:2022-08-05
Last Update Date:2022-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209.025606363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL209.025606OtherSTATE OF ILLINOIS APRN LICENSE