Provider Demographics
NPI:1942753082
Name:NICHOLS, MICHELLE ANN (AGNP-C)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:ANN
Last Name:NICHOLS
Suffix:
Gender:F
Credentials:AGNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1716 HARTFORD ST.
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:IN
Mailing Address - Zip Code:47904-2138
Mailing Address - Country:US
Mailing Address - Phone:765-742-1567
Mailing Address - Fax:765-429-2700
Practice Address - Street 1:1716 HARTFORD ST.
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:IN
Practice Address - Zip Code:47904-2138
Practice Address - Country:US
Practice Address - Phone:765-742-1567
Practice Address - Fax:765-429-2700
Is Sole Proprietor?:No
Enumeration Date:2016-07-25
Last Update Date:2016-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28096862A363LA2200X, 163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
INPENDINGMedicaid
INPENDINGOtherANTHEM PROVIDER NUMBER
INPENDINGMedicare PIN