Healthcare Provider Details

I. General information

NPI: 1699695452
Provider Name (Legal Business Name): AMANDA ANTONIETTA NELSON NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/20/2026
Last Update Date: 09/24/2026
Certification Date: 09/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3500 FRANCISCAN WAY STE 400
MICHIGAN CITY IN
46360-0033
US

IV. Provider business mailing address

PO BOX 781076
DETROIT MI
48278-1076
US

V. Phone/Fax

Practice location:
  • Phone: 219-879-8511
  • Fax: 219-878-8333
Mailing address:
  • Phone: 317-528-4800
  • Fax: 317-865-1479

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number71018622A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number28174110A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: