Healthcare Provider Details

I. General information

NPI: 1144193178
Provider Name (Legal Business Name): ADDISTYN TRUDI NUNLEY PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/25/2025
Last Update Date: 12/05/2025
Certification Date: 12/05/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1411 S CREASY LN STE 120
LAFAYETTE IN
47905-7433
US

IV. Provider business mailing address

1411 S CREASY LN STE 120
LAFAYETTE IN
47905-7433
US

V. Phone/Fax

Practice location:
  • Phone: 765-447-4165
  • Fax: 765-446-5317
Mailing address:
  • Phone: 765-447-4165
  • Fax: 765-446-5317

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number10005127A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: