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General NPI Number Information
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NPI Number | 1982635587
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Entity Type | Individual
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Provider Name | NICOLE LEIGH FORNALIK PA-C
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Gender | Female
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Dates
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Enumeration Date | 07/05/2006
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Last Update Date | 07/15/2025
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Provider Practice Location Address
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Address Line | 8040 CLEARVISTA PKWY STE 490
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City | INDIANAPOLIS
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State | IN
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Zip | 46256-5604
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Country | US
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Telephone | 317-621-5450
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Fax | 317-621-5453
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Provider Business Mailing Address
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Address Line | 6626 E 75TH ST STE 500
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City | INDIANAPOLIS
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State | IN
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Zip | 46250-2890
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363AS0400X
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Taxonomy Name | Surgical Physician Assistant
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License Number | 10000784A
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License Number State | IN
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Taxonomy #2
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Taxonomy Code | 363AM0700X
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Taxonomy Name | Medical Physician Assistant
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License Number | 10000784A
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License Number State | IN
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Taxonomy #3
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number | 10000784A
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License Number State | IN
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