Provider Demographics
NPI:1104341684
Name:FISH, MICHELLE S (NP)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:S
Last Name:FISH
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6626 E 75TH ST STE 500
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46250-2890
Mailing Address - Country:US
Mailing Address - Phone:317-621-1647
Mailing Address - Fax:
Practice Address - Street 1:1400 N RITTER AVE STE 370
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46219-3098
Practice Address - Country:US
Practice Address - Phone:317-355-1144
Practice Address - Fax:317-355-1155
Is Sole Proprietor?:No
Enumeration Date:2017-08-07
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28153865A163W00000X
IN71007449A363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN300005878Medicaid