Provider Demographics
NPI:1902487689
Name:NICKLES, MELISSA ASHLEY
Entity type:Individual
Prefix:
First Name:MELISSA
Middle Name:ASHLEY
Last Name:NICKLES
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 1:1853 W POLK ST # MC785
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60612-4355
Mailing Address - Country:US
Mailing Address - Phone:847-271-1976
Mailing Address - Fax:
Practice Address - Street 1:808 S WOOD ST # 3E
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60612-7300
Practice Address - Country:US
Practice Address - Phone:312-996-8666
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-15
Last Update Date:2024-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL125.079601207R00000X, 207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine