Provider Demographics
NPI:1639248214
Name:NICLEY, AMY A (NP)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:A
Last Name:NICLEY
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:AMY
Other - Middle Name:A
Other - Last Name:HOFFMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1329 W 96TH ST STE 1
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46260-1190
Mailing Address - Country:US
Mailing Address - Phone:317-660-0888
Mailing Address - Fax:
Practice Address - Street 1:1329 W 96TH ST STE 1
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46260-1190
Practice Address - Country:US
Practice Address - Phone:317-660-0888
Practice Address - Fax:317-660-0880
Is Sole Proprietor?:No
Enumeration Date:2006-11-07
Last Update Date:2016-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71002230A363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201094870Medicaid
IN267030IMedicare PIN
IN165460A2Medicare PIN
INQ77231Medicare UPIN