Provider Demographics
NPI:1578049029
Name:ILLICHMANN, NADINE M (DC)
Entity type:Individual
Prefix:
First Name:NADINE
Middle Name:M
Last Name:ILLICHMANN
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2848 MEMORIAL DR STE 9
Mailing Address - Street 2:
Mailing Address - City:TWO RIVERS
Mailing Address - State:WI
Mailing Address - Zip Code:54241-3639
Mailing Address - Country:US
Mailing Address - Phone:920-304-9374
Mailing Address - Fax:
Practice Address - Street 1:2848 MEMORIAL DR STE 9
Practice Address - Street 2:
Practice Address - City:TWO RIVERS
Practice Address - State:WI
Practice Address - Zip Code:54241-3639
Practice Address - Country:US
Practice Address - Phone:920-304-9374
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-18
Last Update Date:2024-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5374-12111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor