MEDICARE: NANCY JANE PAUNICKA RN MS-FNP-CS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LF0000X	Family Nurse Practitioner	71000141A	IN

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	M400075623	OTHER	IN	MEDICARE PTAN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	000000772332	OTHER	IN	ANTHEM BCBS
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1841287299
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	NANCY JANE PAUNICKA RN MS-FNP-CS

Provider Business Mailing Address
First Line	:	PO BOX 1690
Second Line	:
City	:	LA PORTE
State	:	IN
Zip	:	46352-1690
Country	:	US
Telephone Number	:	219-326-2312
Fax Number	:	219-326-2584

Provider Business Practice Location Address
First Line	:	3777 NORTH FRONTAGE ROAD
Second Line	:
City	:	MICHIGAN CITY
State	:	IN
Zip	:	46360-7694
Country	:	US
Telephone Number	:	219-877-3880
Fax Number	:	219-879-6365

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/30/2005
Last Update Date	:	11/28/2012

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