Provider Demographics
NPI:1487705539
Name:SWEAZY, NICOLE J (P T)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:J
Last Name:SWEAZY
Suffix:
Gender:F
Credentials:P T
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:209 N CUMMINGS LN
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:61571-2181
Mailing Address - Country:US
Mailing Address - Phone:309-886-2305
Mailing Address - Fax:309-444-3893
Practice Address - Street 1:209 N CUMMINGS LN
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:IL
Practice Address - Zip Code:61571-2181
Practice Address - Country:US
Practice Address - Phone:309-886-2305
Practice Address - Fax:309-444-3893
Is Sole Proprietor?:No
Enumeration Date:2007-01-16
Last Update Date:2009-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070012965225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL11581915OtherCAQH PROVIDER ID
ILP00751932OtherMEDICARE GROUP MEMBER PTAN
ILP00751932OtherMEDICARE GROUP MEMBER PTAN