Healthcare Provider Details

I. General information

NPI: 1205659323
Provider Name (Legal Business Name): NICOLE M WILSON APN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/06/2024
Last Update Date: 05/19/2025
Certification Date: 05/19/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

429 E VERMONT ST STE 110
INDIANAPOLIS IN
46202-3685
US

IV. Provider business mailing address

429 E VERMONT ST STE 110
INDIANAPOLIS IN
46202-3685
US

V. Phone/Fax

Practice location:
  • Phone: 317-559-0950
  • Fax:
Mailing address:
  • Phone: 317-559-0950
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number209.030991
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number71016247A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: