=====================================================
General NPI Number Information
=====================================================
NPI Number | 1093587420
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ABIGAIL FLACK NP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/30/2023
-----------------------------------------------------
Last Update Date | 05/16/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6326 CONSTITUTION DR
-----------------------------------------------------
City | FORT WAYNE
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46804-1518
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 260-901-9601
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6828 N 300 W
-----------------------------------------------------
City | ROANN
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46974-9669
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax | 260-201-9501
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | 71014421A
-----------------------------------------------------
License Number State | IN
-----------------------------------------------------