Healthcare Provider Details

I. General information

NPI: 1740876887
Provider Name (Legal Business Name): MARY APPLEGATE NUCKOLS I FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/14/2020
Last Update Date: 03/25/2026
Certification Date: 03/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8130 E SOUTHPORT RD
INDIANAPOLIS IN
46259-6806
US

IV. Provider business mailing address

8130 E SOUTHPORT RD
INDIANAPOLIS IN
46259-6806
US

V. Phone/Fax

Practice location:
  • Phone: 317-245-4453
  • Fax:
Mailing address:
  • Phone: 317-245-4453
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number71015228A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: