Provider Demographics
NPI:1497730535
Name:SCOTT, NINA D (NP)
Entity Type:Individual
Prefix:
First Name:NINA
Middle Name:D
Last Name:SCOTT
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3512 STELLHORN RD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46815-4631
Mailing Address - Country:US
Mailing Address - Phone:260-483-9081
Mailing Address - Fax:260-483-9196
Practice Address - Street 1:3512 STELLHORN RD
Practice Address - Street 2:SUITE 100
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46815-4631
Practice Address - Country:US
Practice Address - Phone:260-483-9081
Practice Address - Fax:260-483-9196
Is Sole Proprietor?:No
Enumeration Date:2005-12-13
Last Update Date:2017-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28104970163W00000X
IN71000026363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN500005028OtherRR MEDICARE
IN100359310AMedicaid
IN715320DMedicare ID - Type Unspecified
INR34140Medicare UPIN