Healthcare Provider Details

I. General information

NPI: 1891853644
Provider Name (Legal Business Name): SUE ELLYN NOTTINGHAM FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/05/2006
Last Update Date: 10/26/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11530 ALLISONVILLE RD STE 100
FISHERS IN
46038-1862
US

IV. Provider business mailing address

10330 N MERIDIAN ST # 300
INDIANAPOLIS IN
46290-1024
US

V. Phone/Fax

Practice location:
  • Phone: 317-415-5900
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number71000515
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: