Provider Demographics
NPI:1063230050
Name:FANAJ, NELLO NICOLE
Entity type:Individual
Prefix:
First Name:NELLO
Middle Name:NICOLE
Last Name:FANAJ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:454 E STOP 11 RD
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46227-2560
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:454 E STOP 11 RD
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46227-2560
Practice Address - Country:US
Practice Address - Phone:317-789-3640
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-09-30
Last Update Date:2024-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103TS0200X
IN103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN103TS0200XMedicaid