Provider Demographics
NPI:1942560149
Name:NEKIC, STACI L (NP)
Entity Type:Individual
Prefix:
First Name:STACI
Middle Name:L
Last Name:NEKIC
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:STACI
Other - Middle Name:L
Other - Last Name:ALTMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:PO BOX 1026
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46206-1026
Mailing Address - Country:US
Mailing Address - Phone:317-777-6435
Mailing Address - Fax:317-777-6644
Practice Address - Street 1:211 N EDDY ST
Practice Address - Street 2:
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46617-2808
Practice Address - Country:US
Practice Address - Phone:574-204-6650
Practice Address - Fax:574-204-6659
Is Sole Proprietor?:No
Enumeration Date:2012-05-21
Last Update Date:2016-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71005133363LP0200X
IN28215108A363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201264510Medicaid
IN201264510Medicaid