Healthcare Provider Details

I. General information

NPI: 1407101645
Provider Name (Legal Business Name): BAILEY NICOLE TRESENRITER PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/13/2012
Last Update Date: 02/27/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

801 WAYNE ST
MIDDLEBURY IN
46540-9074
US

IV. Provider business mailing address

22818 OLD US 20
ELKHART IN
46516-9150
US

V. Phone/Fax

Practice location:
  • Phone: 574-389-1231
  • Fax: 574-389-1232
Mailing address:
  • Phone: 574-389-1231
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number10001404A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: