Healthcare Provider Details

I. General information

NPI: 1861297707
Provider Name (Legal Business Name): NICOLETTE ANGELA KRUZICH PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/14/2025
Last Update Date: 02/14/2025
Certification Date: 02/14/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8111 S EMERSON AVE
INDIANAPOLIS IN
46237-8601
US

IV. Provider business mailing address

21041 OAK RIDGE RD
SHERIDAN IN
46069-9720
US

V. Phone/Fax

Practice location:
  • Phone: 317-528-5000
  • Fax:
Mailing address:
  • Phone: 847-363-8677
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: