MEDICARE: DR. NICHOLE LANDRY LEPAGE MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207ZP0102X	Anatomic Pathology & Clinical Pathology Physician	11019395A	IN
2	207ZP0105X	Clinical Pathology/Laboratory Medicine Physician	01085067A	IN

General Provider Information

NPI Number	:	1225558125
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. NICHOLE LANDRY LEPAGE MD

Provider Business Mailing Address
First Line	:	250 N SHADELAND AVE
Second Line	:
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46219-4959
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	350 WEST 11TH STREET
Second Line	:	SUITE 4083
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46202
Country	:	US
Telephone Number	:	317-625-3784
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/21/2017
Last Update Date	:	06/13/2022

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