Healthcare Provider Details

I. General information

NPI: 1316424344
Provider Name (Legal Business Name): NICOLE AMBER KESTUFSKIE PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: NICOLE AMBER ZIMMERMAN PA

II. Dates (important events)

Enumeration Date: 07/23/2018
Last Update Date: 03/18/2021
Certification Date: 03/18/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8244 E US HIGHWAY 36 STE 1100
AVON IN
46123
US

IV. Provider business mailing address

8244 E US HIGHWAY 36 STE 1100
AVON IN
46123-9627
US

V. Phone/Fax

Practice location:
  • Phone: 317-272-7500
  • Fax: 317-272-7515
Mailing address:
  • Phone: 317-272-7500
  • Fax: 317-272-7515

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: