MEDICARE: LAURAN BETTE NICHOLS FNP-C

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	363LF0000X	Family Nurse Practitioner	71009693A	IN

General Provider Information

NPI Number	:	1578194767
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LAURAN BETTE NICHOLS FNP-C

Provider Business Mailing Address
First Line	:	3839 E STATE ROAD 32
Second Line	:
City	:	CRAWFORDSVILLE
State	:	IN
Zip	:	47933-9618
Country	:	US
Telephone Number	:	765-366-8217
Fax Number	:

Provider Business Practice Location Address
First Line	:	1720 LAFAYETTE RD STE A
Second Line	:
City	:	CRAWFORDSVILLE
State	:	IN
Zip	:	47933-4603
Country	:	US
Telephone Number	:	765-323-2828
Fax Number	:

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

Provider Enumeration Date	:	01/28/2020
Last Update Date	:	01/28/2020

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