Provider Demographics
NPI:1447901079
Name:NICKELSON, IEASHA (RN)
Entity type:Individual
Prefix:
First Name:IEASHA
Middle Name:
Last Name:NICKELSON
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1112 W BOUGHTON RD STE 249
Mailing Address - Street 2:
Mailing Address - City:BOLINGBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60440-1508
Mailing Address - Country:US
Mailing Address - Phone:708-949-0969
Mailing Address - Fax:
Practice Address - Street 1:1440 CLEAR DR
Practice Address - Street 2:
Practice Address - City:BOLINGBROOK
Practice Address - State:IL
Practice Address - Zip Code:60490-5575
Practice Address - Country:US
Practice Address - Phone:708-949-0969
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-14
Last Update Date:2022-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
291U00000X
IL041393629163WX0106X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WX0106XNursing Service ProvidersRegistered NurseOccupational Health
No291U00000XLaboratoriesClinical Medical Laboratory