Healthcare Provider Details

I. General information

NPI: 1376070847
Provider Name (Legal Business Name): JANNA KASTING NICKOLL FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MRS. JANNA LYNN CONRAD

II. Dates (important events)

Enumeration Date: 05/16/2017
Last Update Date: 07/08/2025
Certification Date: 07/08/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3015 10TH ST
COLUMBUS IN
47201-7090
US

IV. Provider business mailing address

PO BOX 775383
CHICAGO IL
60677-5383
US

V. Phone/Fax

Practice location:
  • Phone: 812-372-8426
  • Fax: 812-378-7777
Mailing address:
  • Phone: 812-376-5315
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WC0200X
TaxonomyCritical Care Medicine Registered Nurse
License Number28135072A
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number71007158A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: