Provider Demographics
NPI:1336377670
Name:O'ROURKE, NICOLE L (NP)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:L
Last Name:O'ROURKE
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9365 COUNSELORS ROW STE 210
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46240-6418
Mailing Address - Country:US
Mailing Address - Phone:317-429-0120
Mailing Address - Fax:317-800-7730
Practice Address - Street 1:1919 E 52ND ST STE 200
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46205-1381
Practice Address - Country:US
Practice Address - Phone:317-429-0120
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-06-25
Last Update Date:2024-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71002948A207QG0300X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201108760Medicaid
IN165460G8Medicare PIN
IN201108760Medicaid
IN267030JMedicare PIN
IN264910027Medicare PIN