Provider Demographics
NPI:1922712058
Name:MINNICH, NICOLE JOY
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:JOY
Last Name:MINNICH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 TAMARACK DR
Mailing Address - Street 2:
Mailing Address - City:WAKARUSA
Mailing Address - State:IN
Mailing Address - Zip Code:46573-6100
Mailing Address - Country:US
Mailing Address - Phone:574-370-6440
Mailing Address - Fax:
Practice Address - Street 1:600 EAST BLVD
Practice Address - Street 2:
Practice Address - City:ELKHART
Practice Address - State:IN
Practice Address - Zip Code:46514-2483
Practice Address - Country:US
Practice Address - Phone:742-673-2005
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-12
Last Update Date:2023-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant