Provider Demographics
NPI:1982635587
Name:FORNALIK, NICOLE LEIGH (PA-C)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:LEIGH
Last Name:FORNALIK
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:LEIGH
Other - Last Name:FLANDERS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:100 E WAYNE ST STE 510
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46601-2394
Mailing Address - Country:US
Mailing Address - Phone:574-334-5400
Mailing Address - Fax:
Practice Address - Street 1:5340 HOLY CROSS PKWY
Practice Address - Street 2:
Practice Address - City:MISHAWAKA
Practice Address - State:IN
Practice Address - Zip Code:46545-1470
Practice Address - Country:US
Practice Address - Phone:574-237-1328
Practice Address - Fax:574-237-1348
Is Sole Proprietor?:No
Enumeration Date:2006-07-05
Last Update Date:2023-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN10000784A363AM0700X, 363AS0400X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN300007442Medicaid
IN940550D5Medicare PIN