Healthcare Provider Details

I. General information

NPI: 1467927392
Provider Name (Legal Business Name): NICOLE HANISH OD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/08/2018
Last Update Date: 04/21/2026
Certification Date: 04/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1537 S SCATTERFIELD RD STE B
ANDERSON IN
46016-5783
US

IV. Provider business mailing address

1200 W DEYOUNG ST
MARION IL
62959-4437
US

V. Phone/Fax

Practice location:
  • Phone: 765-649-1200
  • Fax: 765-649-4040
Mailing address:
  • Phone: 618-993-5686
  • Fax: 618-993-0031

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number046.011370
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number18004133A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: