Provider Demographics
NPI:1619361037
Name:MINIUK, NICOLE D M (MS, FNP-BC)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:D M
Last Name:MINIUK
Suffix:
Gender:F
Credentials:MS, FNP-BC
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:D M
Other - Last Name:LEE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:BS, RN
Mailing Address - Street 1:123 S MCKINLEY AVE
Mailing Address - Street 2:
Mailing Address - City:RENSSELAER
Mailing Address - State:IN
Mailing Address - Zip Code:47978-2949
Mailing Address - Country:US
Mailing Address - Phone:219-866-7222
Mailing Address - Fax:219-866-7001
Practice Address - Street 1:123 S MCKINLEY AVE
Practice Address - Street 2:
Practice Address - City:RENSSELAER
Practice Address - State:IN
Practice Address - Zip Code:47978-2949
Practice Address - Country:US
Practice Address - Phone:219-866-7222
Practice Address - Fax:219-866-7001
Is Sole Proprietor?:No
Enumeration Date:2015-03-24
Last Update Date:2015-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28192832A163WG0000X
IL041386097163WG0000X
IL209011762163WG0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WG0000XNursing Service ProvidersRegistered NurseGeneral Practice