Healthcare Provider Details

I. General information

NPI: 1922712058
Provider Name (Legal Business Name): NICOLE JOY MINNICH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/12/2023
Last Update Date: 01/05/2026
Certification Date: 01/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6913 N MAIN ST
GRANGER IN
46530-8039
US

IV. Provider business mailing address

3245 HEALTH DR STE 100
GRANGER IN
46530-1380
US

V. Phone/Fax

Practice location:
  • Phone: 574-647-1500
  • Fax: 574-243-4306
Mailing address:
  • Phone: 574-647-3725
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number10004130A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: