Healthcare Provider Details

I. General information

NPI: 1508435074
Provider Name (Legal Business Name): NICOLETTE MICHALEK
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/21/2021
Last Update Date: 06/21/2021
Certification Date: 06/21/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

888 W NEW RD
GREENFIELD IN
46140-7304
US

IV. Provider business mailing address

1 MEMORIAL SQ STE 50
GREENFIELD IN
46140-1357
US

V. Phone/Fax

Practice location:
  • Phone: 317-468-6112
  • Fax:
Mailing address:
  • Phone: 317-468-6257
  • Fax: 317-468-6268

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number05007477A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: