Provider Demographics
NPI:1063726982
Name:SULECKI, LAURA M (NP)
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:M
Last Name:SULECKI
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:LAURA
Other - Middle Name:
Other - Last Name:LIEPNIEKS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 1026
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46206-1026
Mailing Address - Country:US
Mailing Address - Phone:317-274-1201
Mailing Address - Fax:317-278-9905
Practice Address - Street 1:705 RILEY HOSPITAL DR
Practice Address - Street 2:RI 1601
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46202-5109
Practice Address - Country:US
Practice Address - Phone:317-944-4846
Practice Address - Fax:317-948-0126
Is Sole Proprietor?:No
Enumeration Date:2010-08-03
Last Update Date:2011-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28131573363LP0200X
IN71001308363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200993780Medicaid