Provider Demographics
NPI:1831896471
Name:POTEET, NICOLE DANIELLE (NP)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:DANIELLE
Last Name:POTEET
Suffix:
Gender:
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:250 N SHADELAND AVE
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46219-4959
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:404 E WASHINGTON ST STE A
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46204-2609
Practice Address - Country:US
Practice Address - Phone:317-963-2610
Practice Address - Fax:317-963-2615
Is Sole Proprietor?:No
Enumeration Date:2023-02-14
Last Update Date:2025-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28236152A163W00000X
IN71013600A363LF0000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN300072210Medicaid
IN068010913OtherMEDICARE PTAN