Provider Demographics
NPI:1992954986
Name:MINICK, NATOSHA E (NP)
Entity type:Individual
Prefix:MRS
First Name:NATOSHA
Middle Name:E
Last Name:MINICK
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 1:1234 E. DUPONT RD.
Mailing Address - Street 2:STE 1
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46825-1545
Mailing Address - Country:US
Mailing Address - Phone:260-373-9700
Mailing Address - Fax:260-373-9740
Practice Address - Street 1:11109 PARKVIEW PLAZA DR.
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46845-1701
Practice Address - Country:US
Practice Address - Phone:260-266-2020
Practice Address - Fax:260-266-2009
Is Sole Proprietor?:No
Enumeration Date:2008-09-15
Last Update Date:2013-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28162741A163W00000X
IN71002766A363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000739557OtherANTHEM
IN0057278Medicaid
IN200920620Medicaid
IN200920620Medicaid
IN252560FMedicare PIN