Healthcare Provider Details

I. General information

NPI: 1811358963
Provider Name (Legal Business Name): NICOLE K SPEARS RD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/17/2016
Last Update Date: 04/16/2024
Certification Date: 04/16/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

550 UNIVERSITY BLVD
INDIANAPOLIS IN
46202-5149
US

IV. Provider business mailing address

550 UNIVERSITY BLVD
INDIANAPOLIS IN
46202-5149
US

V. Phone/Fax

Practice location:
  • Phone: 317-962-8409
  • Fax: 317-962-2474
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number37002648A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: