Provider Demographics
NPI:1710595111
Name:BLYTHE, NICOLE MICHELLE TABATABAI (DNP, PMHNP-BC)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:MICHELLE TABATABAI
Last Name:BLYTHE
Suffix:
Gender:F
Credentials:DNP, PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1400 W RANDOLPH ST UNIT 1402
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60607-1434
Mailing Address - Country:US
Mailing Address - Phone:217-622-4976
Mailing Address - Fax:
Practice Address - Street 1:159 N SANGAMON ST RM 266
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60607-2201
Practice Address - Country:US
Practice Address - Phone:516-505-7200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-21
Last Update Date:2024-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209029818363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health