Healthcare Provider Details

I. General information

NPI: 1083442735
Provider Name (Legal Business Name): GISELLE NEIDANA MARTINEZ NORIEGA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/24/2024
Last Update Date: 08/22/2024
Certification Date: 08/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

930 MEZZANINE DR
LAFAYETTE IN
47905-8631
US

IV. Provider business mailing address

6377 GREEN GRASS LN
WHITESTOWN IN
46075-9733
US

V. Phone/Fax

Practice location:
  • Phone: 765-607-6160
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number28267646A
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number71015519A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: