Healthcare Provider Details

I. General information

NPI: 1275452351
Provider Name (Legal Business Name): DAWN NICCUM RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/13/2026
Last Update Date: 07/13/2026
Certification Date: 07/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4205 E 200 N
LAFAYETTE IN
47905-7871
US

IV. Provider business mailing address

4205 E 200 N
LAFAYETTE IN
47905-7871
US

V. Phone/Fax

Practice location:
  • Phone: 765-586-7154
  • Fax:
Mailing address:
  • Phone: 765-586-7154
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number28111746A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: