Healthcare Provider Details

I. General information

NPI: 1205536778
Provider Name (Legal Business Name): NYKOLE MARIE ZIMMERMAN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/03/2023
Last Update Date: 05/24/2026
Certification Date: 05/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2040 PEACE TREE VLG
ROCHESTER IN
46975-2630
US

IV. Provider business mailing address

2040 PEACE TREE VLG
ROCHESTER IN
46975-2630
US

V. Phone/Fax

Practice location:
  • Phone: 574-688-7080
  • Fax: 574-688-7081
Mailing address:
  • Phone: 574-688-7080
  • Fax: 574-688-7081

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1835P0018X
TaxonomyPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
License Number26030105A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: