Provider Demographics
NPI:1215402243
Name:BERTSCH, NICOLE (MS)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:BERTSCH
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11050 PARKVIEW CIRCLE DR STE 1D
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46845-1739
Mailing Address - Country:US
Mailing Address - Phone:260-266-6949
Mailing Address - Fax:
Practice Address - Street 1:11050 PARKVIEW CIRCLE DR STE 1D
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46845-1739
Practice Address - Country:US
Practice Address - Phone:260-266-6949
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-05
Last Update Date:2018-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1018170300000X
IN74000231A170300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes170300000XOther Service ProvidersGenetic Counselor, MS